Provider Demographics
NPI:1003700303
Name:WHITTAKER, JARED TYLER
Entity type:Individual
Prefix:
First Name:JARED
Middle Name:TYLER
Last Name:WHITTAKER
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 1:650 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-1427
Mailing Address - Country:US
Mailing Address - Phone:540-345-5111
Mailing Address - Fax:
Practice Address - Street 1:650 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-1427
Practice Address - Country:US
Practice Address - Phone:540-293-8087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-03
Last Update Date:2025-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131003017224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant