1235123282 NPI number — MRS. JENNIFER ANNE LAUSTEN III P.T.

Table of content: MRS. JENNIFER ANNE LAUSTEN III P.T. (NPI 1235123282)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235123282 NPI number — MRS. JENNIFER ANNE LAUSTEN III P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAUSTEN
Provider First Name:
JENNIFER
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
III
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAUSTEN
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1235123282
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20817 MINTWOOD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHBURN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20147-4003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-723-1063
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22 FAIRFAX ST SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20175-3616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-669-6100
Provider Business Practice Location Address Fax Number:
703-669-6101
Provider Enumeration Date:
09/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 204C00000X , with the licence number:  2305004038 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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