Provider Demographics
NPI:1114096054
Name:ROYSTER, JENNETTE (NCTMB,CMT)
Entity Type:Individual
Prefix:
First Name:JENNETTE
Middle Name:
Last Name:ROYSTER
Suffix:
Gender:F
Credentials:NCTMB,CMT
Other - Prefix:
Other - First Name:JENNETTE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NCTMB,CMT
Mailing Address - Street 1:145 BURFORD AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-5864
Mailing Address - Country:US
Mailing Address - Phone:757-392-0414
Mailing Address - Fax:757-392-0417
Practice Address - Street 1:145 BURFORD AVE
Practice Address - Street 2:STE 100
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-5864
Practice Address - Country:US
Practice Address - Phone:757-392-0414
Practice Address - Fax:757-392-0417
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019004402225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist