Provider Demographics
NPI:1205151537
Name:NICELY, JENNIFER R (LPTA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:NICELY
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 103
Mailing Address - Street 2:
Mailing Address - City:IRON GATE
Mailing Address - State:VA
Mailing Address - Zip Code:24448-0103
Mailing Address - Country:US
Mailing Address - Phone:540-862-1662
Mailing Address - Fax:
Practice Address - Street 1:1000 FAIRVIEW AVENUE
Practice Address - Street 2:
Practice Address - City:CLIFTON FORGE
Practice Address - State:VA
Practice Address - Zip Code:24422-1990
Practice Address - Country:US
Practice Address - Phone:540-862-9555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306602542225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant