Provider Demographics
NPI:1396115010
Name:FAHERTY, JENNIFER (MOT, OTR/L)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FAHERTY
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 TACKETTS MILL DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-3036
Mailing Address - Country:US
Mailing Address - Phone:703-491-1044
Mailing Address - Fax:703-491-2044
Practice Address - Street 1:2235 TACKETTS MILL DR
Practice Address - Street 2:SUITE C
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3036
Practice Address - Country:US
Practice Address - Phone:703-491-1044
Practice Address - Fax:703-491-2044
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119006741225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist