Provider Demographics
NPI:1114427416
Name:EDA, JENNIFER LEE (ATC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:EDA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 BOXFORD RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-5007
Mailing Address - Country:US
Mailing Address - Phone:175-743-5324
Mailing Address - Fax:
Practice Address - Street 1:4740 BOXFORD RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-5007
Practice Address - Country:US
Practice Address - Phone:757-353-2419
Practice Address - Fax:757-353-2419
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260028652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer