Provider Demographics
NPI:1164689774
Name:HADDEMAN, JACQUELINE ANNE (COTA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANNE
Last Name:HADDEMAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1148 FIRST COLONIAL RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2426
Mailing Address - Country:US
Mailing Address - Phone:757-481-3321
Mailing Address - Fax:
Practice Address - Street 1:1148 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2426
Practice Address - Country:US
Practice Address - Phone:757-481-3321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2719243224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant