Provider Demographics
NPI:1689452708
Name:BRIDWELL, JEANIE
Entity Type:Individual
Prefix:
First Name:JEANIE
Middle Name:
Last Name:BRIDWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44485 POTTER TER
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-7156
Mailing Address - Country:US
Mailing Address - Phone:919-869-0589
Mailing Address - Fax:
Practice Address - Street 1:1801 ROBERT FULTON DR # 230
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-5461
Practice Address - Country:US
Practice Address - Phone:571-449-6839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019014296225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist