MEDICARE: MS. PAMELA DIANE JENKINS OTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	0131002537	VA

General Provider Information

NPI Number	:	1578228409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PAMELA DIANE JENKINS OTA

Provider Business Mailing Address
First Line	:	6343 LOGANS LN APT 3414
Second Line	:
City	:	LYNCHBURG
State	:	VA
Zip	:	24502-5030
Country	:	US
Telephone Number	:	817-716-6306
Fax Number	:

Provider Business Practice Location Address
First Line	:	4428 PHEASANT RIDGE RD
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24014-5219
Country	:	US
Telephone Number	:	540-400-6430
Fax Number	:	540-491-9277

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2021
Last Update Date	:	11/04/2021

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