Provider Demographics
NPI:1336281518
Name:JEFFERSON DAVIS CHIROPRACTIC & PT
Entity Type:Organization
Organization Name:JEFFERSON DAVIS CHIROPRACTIC & PT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:SARA
Authorized Official - Middle Name:HATAM
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-499-8840
Mailing Address - Street 1:14904 JEFFERSON DAVIS HWY
Mailing Address - Street 2:#301
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14904 JEFFERSON DAVIS HWY
Practice Address - Street 2:#301
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191
Practice Address - Country:US
Practice Address - Phone:703-499-8840
Practice Address - Fax:703-499-8842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001683111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty