1417396755 NPI number — MRS. JENNIFER LYNN PIMENTEL OTR

Table of content: MRS. JENNIFER LYNN PIMENTEL OTR (NPI 1417396755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417396755 NPI number — MRS. JENNIFER LYNN PIMENTEL OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PIMENTEL
Provider First Name:
JENNIFER
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O'HEARN
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417396755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
414 LONDON ST
Provider Second Line Business Mailing Address:
APT 3
Provider Business Mailing Address City Name:
PORTSMOUTH
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23704-2546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-205-2990
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7700 ARLINGTON BLVD
Provider Second Line Business Practice Location Address:
STE 5113
Provider Business Practice Location Address City Name:
FALLS CHURCH
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22042-2929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-681-9025
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2013

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: 225X00000X , with the licence number:  310320 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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