Provider Demographics
NPI:1578228409
Name:JENKINS, PAMELA DIANE (OTA)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:DIANE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6343 LOGANS LN APT 3414
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-5030
Mailing Address - Country:US
Mailing Address - Phone:817-716-6306
Mailing Address - Fax:
Practice Address - Street 1:4428 PHEASANT RIDGE RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-5219
Practice Address - Country:US
Practice Address - Phone:540-400-6430
Practice Address - Fax:540-491-9277
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131002537224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty