Provider Demographics
NPI:1124003868
Name:RICCI, JACK G (DC)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:G
Last Name:RICCI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2324 STONERIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2865
Mailing Address - Country:US
Mailing Address - Phone:540-931-1066
Mailing Address - Fax:
Practice Address - Street 1:3119 VALLEY AVE STE 104
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2665
Practice Address - Country:US
Practice Address - Phone:540-662-6284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2016-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX09345111N00000X
WV892111N00000X
VA0104556410111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor