Healthcare Provider Details

I. General information

NPI: 1063101707
Provider Name (Legal Business Name): JENA ALLEY DAVIDSON LPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RANDOLPH ST
RADFORD VA
24141
US

IV. Provider business mailing address

115 TALUS LN NW APT 205
CHRISTIANSBURG VA
24073
US

V. Phone/Fax

Practice location:
  • Phone: 540-633-6538
  • Fax:
Mailing address:
  • Phone: 276-733-3334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306605901
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: