Provider Demographics
NPI:1033485966
Name:JAGADEESAN, GAYATHRI
Entity Type:Individual
Prefix:
First Name:GAYATHRI
Middle Name:
Last Name:JAGADEESAN
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 1:2120 WORDSWORTH CT APT 202
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-5861
Mailing Address - Country:US
Mailing Address - Phone:571-266-6677
Mailing Address - Fax:
Practice Address - Street 1:2120 WORDSWORTH CT APT 202
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-5861
Practice Address - Country:US
Practice Address - Phone:571-266-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205514225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist