Provider Demographics
NPI:1154734135
Name:MINOR, JAMALL TRIMAINE
Entity type:Individual
Prefix:
First Name:JAMALL
Middle Name:TRIMAINE
Last Name:MINOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4126 DOMINION TOWNES CIR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-2292
Mailing Address - Country:US
Mailing Address - Phone:804-658-3632
Mailing Address - Fax:
Practice Address - Street 1:4126 DOMINION TOWNES CIR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-2292
Practice Address - Country:US
Practice Address - Phone:804-658-3632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2040-03-001101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health