Provider Demographics
NPI:1154886539
Name:TATUM, JACQUELINA OTILIA
Entity type:Individual
Prefix:MISS
First Name:JACQUELINA
Middle Name:OTILIA
Last Name:TATUM
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JACQUELINA
Other - Middle Name:OTILIA
Other - Last Name:CHURHILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6802 PARAGON PL STE 410
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23230-1655
Mailing Address - Country:US
Mailing Address - Phone:919-358-3730
Mailing Address - Fax:844-892-9261
Practice Address - Street 1:6802 PARAGON PL STE 410
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1655
Practice Address - Country:US
Practice Address - Phone:919-358-3730
Practice Address - Fax:844-892-9261
Is Sole Proprietor?:No
Enumeration Date:2019-02-09
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XM0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistMental Health