Provider Demographics
NPI:1053556209
Name:STEPHENSON, JACQUELYN G (CNM)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:G
Last Name:STEPHENSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MISS
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:667 KINGSBOROUGH SQ STE 101
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4999
Mailing Address - Country:US
Mailing Address - Phone:757-842-4481
Mailing Address - Fax:757-312-3135
Practice Address - Street 1:113 GAINSBOROUGH SQ STE 201
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-1714
Practice Address - Country:US
Practice Address - Phone:757-842-4620
Practice Address - Fax:757-842-4621
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001137127163W00000X
VA0024164424363L00000X, 176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1053556209Medicaid
VA1053556209Medicaid
VAP00757867Medicare PIN