=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710461835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA NICOLE PECKHAM LPTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2018
-----------------------------------------------------
Last Update Date | 09/25/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33 WINSTON AVE
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23601-2227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-897-2261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 WINSTON AVE
-----------------------------------------------------
City | NEWPORT NEWS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23601-2227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-897-2261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2306605001
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------