Provider Demographics
NPI:1962921395
Name:WAIDELICH, JENNIFER (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WAIDELICH
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 1:2228 WINDY PINES BND
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-3930
Mailing Address - Country:US
Mailing Address - Phone:609-658-9191
Mailing Address - Fax:
Practice Address - Street 1:410 E AVE
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118
Practice Address - Country:US
Practice Address - Phone:609-658-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211035225100000X
CA293722225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist