Provider Demographics
NPI:1396707337
Name:TENA, BRANDIE JACKSON (DPT)
Entity type:Individual
Prefix:DR
First Name:BRANDIE
Middle Name:JACKSON
Last Name:TENA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3902 ROCHAMBEAU DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-6620
Mailing Address - Country:US
Mailing Address - Phone:757-707-0945
Mailing Address - Fax:
Practice Address - Street 1:771 PILOT HOUSE DRIVE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606
Practice Address - Country:US
Practice Address - Phone:757-873-2123
Practice Address - Fax:757-873-3848
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305203940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010105536Medicaid
7709582OtherAETNA
VAP00140465OtherRAILROAD MEDICARE
Q22481Medicare UPIN