Healthcare Provider Details

I. General information

NPI: 1508790973
Provider Name (Legal Business Name): ELISE JERNIGAN OTD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9229 ARLINGTON BLVD
FAIRFAX VA
22031-2550
US

IV. Provider business mailing address

1340 21ST ST NW
WASHINGTON DC
20036-1568
US

V. Phone/Fax

Practice location:
  • Phone: 703-782-8972
  • Fax:
Mailing address:
  • Phone: 757-320-8496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119011541
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: