Healthcare Provider Details

I. General information

NPI: 1548086523
Provider Name (Legal Business Name): JENNIFER ERIN LUTTERLOH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16970 STAGE RD
LANEXA VA
23089-5241
US

IV. Provider business mailing address

16970 STAGE RD
LANEXA VA
23089-5241
US

V. Phone/Fax

Practice location:
  • Phone: 757-870-2386
  • Fax:
Mailing address:
  • Phone: 757-870-2386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number$$$$$$$$$
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: