Provider Demographics
NPI:1962702704
Name:HAYNIE, JESSICA R (DPT)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:R
Last Name:HAYNIE
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 1:9215 WIGNEIL ST
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23433-1530
Mailing Address - Country:US
Mailing Address - Phone:757-650-2513
Mailing Address - Fax:
Practice Address - Street 1:15314 CARROLLTON BLVD
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:VA
Practice Address - Zip Code:23314-2304
Practice Address - Country:US
Practice Address - Phone:757-650-2513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206723225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist