MEDICARE: JAYE CLABAUGH 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	2251P0200X	Pediatric Physical Therapist	2305001943	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	270929	OTHER	VA	MAMSI

General Provider Information

NPI Number	:	1659592640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAYE CLABAUGH P.T.

Provider Business Mailing Address
First Line	:	301 N FAIRFAX ST
Second Line	:	SUITE 106
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-2635
Country	:	US
Telephone Number	:	703-836-1083
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 N FAIRFAX ST
Second Line	:	SUITE 106
City	:	ALEXANDRIA
State	:	VA
Zip	:	22314-2635
Country	:	US
Telephone Number	:	703-836-1083
Fax Number	:

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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