Healthcare Provider Details

I. General information

NPI: 1245160225
Provider Name (Legal Business Name): JASON EMANNUEL BALDWIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 S INDEPENDENCE BLVD STE 1A
VIRGINIA BEACH VA
23453-4773
US

IV. Provider business mailing address

2076 S INDEPENDENCE BLVD STE 1A
VIRGINIA BEACH VA
23453-4773
US

V. Phone/Fax

Practice location:
  • Phone: 757-302-4144
  • Fax:
Mailing address:
  • Phone: 757-302-4144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306606891
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: