Healthcare Provider Details

I. General information

NPI: 1306765045
Provider Name (Legal Business Name): JENNIFER BAKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER ROACH

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2405 ATHERHOLT RD
LYNCHBURG VA
24501-2184
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 434-485-8517
  • Fax: 434-485-8594
Mailing address:
  • Phone: 804-915-1910
  • Fax: 804-968-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110012326
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: