Provider Demographics
NPI:1902294028
Name:LUEDTKE, JOCELYN
Entity Type:Individual
Prefix:
First Name:JOCELYN
Middle Name:
Last Name:LUEDTKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17302 SIMMONS RD
Mailing Address - Street 2:
Mailing Address - City:PURCELLVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20132-3529
Mailing Address - Country:US
Mailing Address - Phone:402-689-6619
Mailing Address - Fax:
Practice Address - Street 1:21750 RED RUM DR STE 117
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-5867
Practice Address - Country:US
Practice Address - Phone:703-574-2989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-23
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
VA0119010239225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No172V00000XOther Service ProvidersCommunity Health Worker