Healthcare Provider Details

I. General information

NPI: 1891699799
Provider Name (Legal Business Name): JACOB PATTERSON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14348 GIDEON DR
WOODBRIDGE VA
22192-4640
US

IV. Provider business mailing address

14348 GIDEON DR
WOODBRIDGE VA
22192-4640
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-1330
  • Fax:
Mailing address:
  • Phone: 703-490-1330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2306606824
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: