Provider Demographics
NPI:1235123282
Name:LAUSTEN, JENNIFER ANNE III (PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANNE
Last Name:LAUSTEN
Suffix:III
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:LAUSTEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:20817 MINTWOOD CT
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4003
Mailing Address - Country:US
Mailing Address - Phone:703-723-1063
Mailing Address - Fax:
Practice Address - Street 1:22 FAIRFAX ST SE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-3616
Practice Address - Country:US
Practice Address - Phone:703-669-6100
Practice Address - Fax:703-669-6101
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305004038204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000008T63Medicare ID - Type UnspecifiedPHYSICAL THERAPIST