MEDICARE: MRS. JENNIFER ANNE LAUSTEN III P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204C00000X	Sports Medicine (Neuromusculoskeletal Medicine) Physician	2305004038	VA

General Provider Information

NPI Number	:	1235123282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JENNIFER ANNE LAUSTEN III P.T.

Provider Business Mailing Address
First Line	:	20817 MINTWOOD CT
Second Line	:
City	:	ASHBURN
State	:	VA
Zip	:	20147-4003
Country	:	US
Telephone Number	:	703-723-1063
Fax Number	:

Provider Business Practice Location Address
First Line	:	22 FAIRFAX ST SE
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20175-3616
Country	:	US
Telephone Number	:	703-669-6100
Fax Number	:	703-669-6101

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	07/08/2007

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