Healthcare Provider Details

I. General information

NPI: 1952780603
Provider Name (Legal Business Name): JAKE PLAIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9447B LORTON MARKET ST SUITE 250
LORTON VA
22079-1963
US

IV. Provider business mailing address

9447B LORTON MARKET ST SUITE 250
LORTON VA
22079-1963
US

V. Phone/Fax

Practice location:
  • Phone: 703-372-5716
  • Fax:
Mailing address:
  • Phone: 703-372-5716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305209429
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: