Provider Demographics
NPI:1144931163
Name:HIATT, JENNIFER ANNE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:HIATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4117 SHERINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-1218
Mailing Address - Country:US
Mailing Address - Phone:804-920-3819
Mailing Address - Fax:
Practice Address - Street 1:4117 SHERINGHAM RD
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236-1218
Practice Address - Country:US
Practice Address - Phone:804-920-3819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019015487225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist