Healthcare Provider Details

I. General information

NPI: 1174758460
Provider Name (Legal Business Name): JENA GROSS NORTHEN MS, OTR/L, BCN, SIPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 01/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4840 WALLER RD SUITE 200
RICHMOND VA
23230-2912
US

IV. Provider business mailing address

4840 WALLER RD SUITE 200
RICHMOND VA
23230-2912
US

V. Phone/Fax

Practice location:
  • Phone: 804-893-5010
  • Fax: 804-412-8105
Mailing address:
  • Phone: 804-893-5010
  • Fax: 804-412-8105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119001176
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: