Provider Demographics
NPI:1629401492
Name:TAIWO, JENNIFER RAE (LPTA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:TAIWO
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RAE
Other - Last Name:POMERVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2003 COBB ST
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-2603
Mailing Address - Country:US
Mailing Address - Phone:434-392-6106
Mailing Address - Fax:
Practice Address - Street 1:2003 COBB ST
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-2603
Practice Address - Country:US
Practice Address - Phone:434-392-6106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603406225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant