Healthcare Provider Details

I. General information

NPI: 1336281518
Provider Name (Legal Business Name): JEFFERSON DAVIS CHIROPRACTIC & PT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14904 JEFFERSON DAVIS HWY #301
WOODBRIDGE VA
22191
US

IV. Provider business mailing address

14904 JEFFERSON DAVIS HWY #301
WOODBRIDGE VA
22102
US

V. Phone/Fax

Practice location:
  • Phone: 703-499-8840
  • Fax: 703-499-8842
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104001683
License Number StateVA

VIII. Authorized Official

Name: SARA HATAM PETERSON
Title or Position: OWNER CHIROPRACTOR
Credential: DC
Phone: 703-499-8840