Provider Demographics
NPI:1508302498
Name:ANDERSON, JESSICA LEAH (PTA)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:LEAH
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3620 APPLEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23234-4821
Mailing Address - Country:US
Mailing Address - Phone:804-221-5010
Mailing Address - Fax:
Practice Address - Street 1:3620 APPLEWOOD RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23234-4821
Practice Address - Country:US
Practice Address - Phone:804-221-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603538225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant