Provider Demographics
NPI:1851978811
Name:ST AUBIN, JENNA (OTR/L)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:ST AUBIN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2901
Mailing Address - Street 2:
Mailing Address - City:MERRIFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22116-2901
Mailing Address - Country:US
Mailing Address - Phone:703-646-2250
Mailing Address - Fax:703-991-5649
Practice Address - Street 1:2841 HARTLAND RD STE 403
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22043-3500
Practice Address - Country:US
Practice Address - Phone:703-646-2250
Practice Address - Fax:703-991-5649
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119009811225X00000X
MD09212225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0119009811OtherOCCUPATIONAL THERAPY LICENSE
VA30017677340001Medicaid