Provider Demographics
NPI:1366975633
Name:DPC JEWETT LLC
Entity type:Organization
Organization Name:DPC JEWETT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:P
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC
Authorized Official - Phone:757-679-6058
Mailing Address - Street 1:702 CITY CENTER BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-3096
Mailing Address - Country:US
Mailing Address - Phone:175-767-9605
Mailing Address - Fax:757-926-5465
Practice Address - Street 1:702 CITY CENTER BLVD STE C
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3096
Practice Address - Country:US
Practice Address - Phone:117-576-7960
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171097302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization