Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 001083 | WV |
Y | 225100000X | Physical Therapist | 02305004220 | VA |
N | 2251G0304X | Physical Therapist - Geriatrics | 001083 | WV |
N | 2251G0304X | Physical Therapist - Geriatrics | 2305004220 | VA |
NPI | 1275187957 |
---|---|
Provider Name | Lauren St Jacques |
First Address | Winchester, VA 22602-7807 |
Second Address | Front Royal, VA 22630-3607 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/07/2019 |
Last Update Date | 30/07/2019 |