Provider Demographics
NPI:1477910347
Name:REGAL, JENNIFER MAGBANUA (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MAGBANUA
Last Name:REGAL
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5604 VIRGINIA BEACH BLVD
Mailing Address - Street 2:BLDG A, SUITE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-5631
Mailing Address - Country:US
Mailing Address - Phone:757-455-5000
Mailing Address - Fax:757-319-4142
Practice Address - Street 1:5604 VIRGINIA BEACH BLVD
Practice Address - Street 2:BLDG A, SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-5631
Practice Address - Country:US
Practice Address - Phone:757-455-5000
Practice Address - Fax:757-319-4142
Is Sole Proprietor?:No
Enumeration Date:2016-01-24
Last Update Date:2016-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist