Basic Information
| Provider Information | |||||||||
| NPI: | 1891957312 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | QUILTER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 FIRST COLONIAL RD | ||||||||
| Address2: | # 1 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234543002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573403489 | ||||||||
| FaxNumber: | 7573404278 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 FIRST COLONIAL RD | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234543002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573958000 | ||||||||
| FaxNumber: | 7573404278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 04/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 0116019909 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208100000X | 0102202788 | VA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1891957312 | 05 | VA | MEDICAID |