Provider Demographics
NPI:1962967554
Name:VELAZQUEZ, JESSICA (PTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:VELAZQUEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 ROSEHILL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-4843
Mailing Address - Country:US
Mailing Address - Phone:888-531-2204
Mailing Address - Fax:855-232-8604
Practice Address - Street 1:103 ROSEHILL DR
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-4843
Practice Address - Country:US
Practice Address - Phone:888-531-2204
Practice Address - Fax:855-232-8604
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant