Provider Demographics
NPI:1740566033
Name:JAIN, PRIYANKA R
Entity Type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:R
Last Name:JAIN
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 1:920 OCCANECCHI TRL
Mailing Address - Street 2:
Mailing Address - City:EBONY
Mailing Address - State:VA
Mailing Address - Zip Code:23845-2046
Mailing Address - Country:US
Mailing Address - Phone:419-575-2747
Mailing Address - Fax:
Practice Address - Street 1:125 BUENA VISTA CIR
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1431
Practice Address - Country:US
Practice Address - Phone:434-447-3054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-31
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202006503235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist