Healthcare Provider Details

I. General information

NPI: 1003700303
Provider Name (Legal Business Name): JARED TYLER WHITTAKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 N JEFFERSON ST
ROANOKE VA
24016-1427
US

IV. Provider business mailing address

650 N JEFFERSON ST
ROANOKE VA
24016-1427
US

V. Phone/Fax

Practice location:
  • Phone: 540-293-8087
  • Fax:
Mailing address:
  • Phone: 540-345-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131003017
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: