Provider Demographics
NPI:1497754501
Name:THIBODEAU, JENNIFER ALLISON (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ALLISON
Last Name:THIBODEAU
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 W JUBAL EARLY DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6446
Mailing Address - Country:US
Mailing Address - Phone:540-450-0680
Mailing Address - Fax:540-450-0681
Practice Address - Street 1:480 W JUBAL EARLY DR
Practice Address - Street 2:SUITE 310
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-6446
Practice Address - Country:US
Practice Address - Phone:540-450-0680
Practice Address - Fax:540-450-0681
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305831302225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00X445P01Medicare PIN