Provider Demographics
NPI:1306900980
Name:DEDIOS, JENNIFER G
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:G
Last Name:DEDIOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:1060 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3002
Practice Address - Country:US
Practice Address - Phone:757-491-9065
Practice Address - Fax:757-395-6321
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010122457Medicaid
VA1306900980Medicaid
VA006299F15Medicare ID - Type Unspecified
VAI03065Medicare UPIN
VA1306900980Medicaid