Provider Demographics
NPI:1184748329
Name:LASTOVA, JENNIFER (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LASTOVA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7675 SWEET HOURS WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-2477
Mailing Address - Country:US
Mailing Address - Phone:410-290-5282
Mailing Address - Fax:
Practice Address - Street 1:7675 SWEET HOURS WAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-2477
Practice Address - Country:US
Practice Address - Phone:410-290-5282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17770225100000X
DCPT2127225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist