Provider Demographics
NPI:1922452820
Name:WAKELYN, JEANNIE (MS ATC LT)
Entity Type:Individual
Prefix:MRS
First Name:JEANNIE
Middle Name:
Last Name:WAKELYN
Suffix:
Gender:F
Credentials:MS ATC LT
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 2129
Mailing Address - Street 2:
Mailing Address - City:POQUOSON
Mailing Address - State:VA
Mailing Address - Zip Code:23662-0129
Mailing Address - Country:US
Mailing Address - Phone:757-880-9165
Mailing Address - Fax:
Practice Address - Street 1:3 ISLAND CT
Practice Address - Street 2:
Practice Address - City:POQUOSON
Practice Address - State:VA
Practice Address - Zip Code:23662-1638
Practice Address - Country:US
Practice Address - Phone:757-880-9165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-17
Last Update Date:2016-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260011512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer