Basic Information
| Provider Information | |||||||||
| NPI: | 1659304293 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARLESS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LINDSEY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | OTR, CHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13000 RIVERS BEND BLVD | ||||||||
| Address2: | STE D | ||||||||
| City: | CHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238368632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045715106 | ||||||||
| FaxNumber: | 8045301857 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 JENNICK DR | ||||||||
| Address2: | |||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238344905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045265888 | ||||||||
| FaxNumber: | 8045265401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 12/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | 0119000261 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | 1659304293 | 05 | VA | MEDICAID | P00401744 | 01 | VA | RAILROAD MEDICARE | OTHER |