Provider Demographics
NPI:1952780603
Name:PLAIN, JAKE
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:PLAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9447B LORTON MARKET ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1963
Mailing Address - Country:US
Mailing Address - Phone:703-372-5716
Mailing Address - Fax:
Practice Address - Street 1:9447B LORTON MARKET ST
Practice Address - Street 2:SUITE 250
Practice Address - City:LORTON
Practice Address - State:VA
Practice Address - Zip Code:22079-1963
Practice Address - Country:US
Practice Address - Phone:703-372-5716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209429225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist