Provider Demographics
NPI:1104178417
Name:ROBERTS, JENNA MARIE (LPTA)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MARIE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 21
Mailing Address - Street 2:874 ROBERTS LN
Mailing Address - City:BEDFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24523
Mailing Address - Country:US
Mailing Address - Phone:540-874-0082
Mailing Address - Fax:
Practice Address - Street 1:1127 PERSINGER RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-3829
Practice Address - Country:US
Practice Address - Phone:540-874-0082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603342225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant