Provider Demographics
NPI:1912091315
Name:HATTINGH, JAN H (CPO)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:H
Last Name:HATTINGH
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44115 WOODBRIGE PARKWAY
Mailing Address - Street 2:SUITE 180
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176
Mailing Address - Country:US
Mailing Address - Phone:571-445-3390
Mailing Address - Fax:571-445-3392
Practice Address - Street 1:44115 WOODBRIGE PARKWAY
Practice Address - Street 2:SUITE 180
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176
Practice Address - Country:US
Practice Address - Phone:571-445-3390
Practice Address - Fax:571-445-3392
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS000000141744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9036963Medicaid
WA9036963Medicaid