Provider Demographics
NPI:1962146720
Name:MASON, JENNIFER DANIELLE
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:DANIELLE
Last Name:MASON
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 1:525 CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-3504
Mailing Address - Country:US
Mailing Address - Phone:804-255-3608
Mailing Address - Fax:
Practice Address - Street 1:2760 FOREST HILLS RD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-2450
Practice Address - Country:US
Practice Address - Phone:804-255-3608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA3763-01-001311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home