MEDICARE: MRS. JESSICA LYN HOLDER DPT

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	225100000X	Physical Therapist	2305205485	VA

General Provider Information

NPI Number	:	1972898179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JESSICA LYN HOLDER DPT

Provider Business Mailing Address
First Line	:	581 CARSON DR
Second Line	:
City	:	SPOUT SPRING
State	:	VA
Zip	:	24593-2606
Country	:	US
Telephone Number	:	434-941-7730
Fax Number	:

Provider Business Practice Location Address
First Line	:	581 CARSON DR
Second Line	:
City	:	SPOUT SPRING
State	:	VA
Zip	:	24593-2606
Country	:	US
Telephone Number	:	434-941-7730
Fax Number	:

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

Provider Enumeration Date	:	06/15/2011
Last Update Date	:	06/15/2011

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