Individual
JESSICA LYNN SOUTHERS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
6800 LUCY CORR CT, CHESTERFIELD, VA 23832-6657
(804) 748-1511
Mailing address
14001 STONECREEK CLUB CT, CHESTERFIELD, VA 23832-2591
(804) 695-6893
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
2306605787
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2306605787
BOARD OF PHYSICAL THERAPY LICENSE
VA
Enumeration date
01/14/2021
Last updated
01/14/2021
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