Provider Demographics
NPI:1902068786
Name:SOUMAH, JENNIFER ELAINE (MBA, MS, LAT, ATC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ELAINE
Last Name:SOUMAH
Suffix:
Gender:F
Credentials:MBA, MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10256 CHERRY WALK CT
Mailing Address - Street 2:
Mailing Address - City:OAKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22124-2532
Mailing Address - Country:US
Mailing Address - Phone:317-965-2333
Mailing Address - Fax:
Practice Address - Street 1:10256 CHERRY WALK CT
Practice Address - Street 2:
Practice Address - City:OAKTON
Practice Address - State:VA
Practice Address - Zip Code:22124-2532
Practice Address - Country:US
Practice Address - Phone:317-965-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001126A2255A2300X
VA01260029532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer