Provider Demographics
NPI:1942435391
Name:HOLLANDSWORTH, JERRY LYNN JR (LPTA)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:LYNN
Last Name:HOLLANDSWORTH
Suffix:JR
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1129 MACKS MOUNTAIN RD NW
Mailing Address - Street 2:
Mailing Address - City:INDIAN VALLEY
Mailing Address - State:VA
Mailing Address - Zip Code:24105-3125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-2430
Practice Address - Country:US
Practice Address - Phone:540-633-3708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306601670225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant