Provider Demographics
NPI:1609899707
Name:RICH, JENNIFER MARIE (PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:RICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2302 COLONIAL AVE SW STE G
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-3100
Mailing Address - Country:US
Mailing Address - Phone:540-982-8873
Mailing Address - Fax:540-982-2274
Practice Address - Street 1:2302 COLONIAL AVE SW STE G
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-3100
Practice Address - Country:US
Practice Address - Phone:540-982-8873
Practice Address - Fax:540-982-2274
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305005536174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00W060J01Medicare PIN