Provider Demographics
NPI:1639716749
Name:PETERSON, JARVARIUS (PTA)
Entity Type:Individual
Prefix:
First Name:JARVARIUS
Middle Name:
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5613 BELL ST
Mailing Address - Street 2:
Mailing Address - City:NORTH DINWIDDIE
Mailing Address - State:VA
Mailing Address - Zip Code:23803-8933
Mailing Address - Country:US
Mailing Address - Phone:804-926-6461
Mailing Address - Fax:
Practice Address - Street 1:10300 COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832
Practice Address - Country:US
Practice Address - Phone:804-203-1991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604599225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant