Provider Demographics
NPI:1164694402
Name:RAQUENO, JEANZEN MICHELLE LINTAG (PT)
Entity Type:Individual
Prefix:MRS
First Name:JEANZEN MICHELLE
Middle Name:LINTAG
Last Name:RAQUENO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JEANZEN MICHELLE
Other - Middle Name:BERNABE
Other - Last Name:LINTAG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1501 BLUEBALL AVE
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19061-3922
Mailing Address - Country:US
Mailing Address - Phone:610-859-8850
Mailing Address - Fax:610-672-9936
Practice Address - Street 1:1078 S STATE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-6925
Practice Address - Country:US
Practice Address - Phone:302-678-2397
Practice Address - Fax:302-678-2399
Is Sole Proprietor?:No
Enumeration Date:2008-03-27
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0002167225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE295853OtherUNISON
DE1164694402Medicaid
3761297000OtherIBC PERSONAL CHOICE
12033691OtherCAQH
12033691OtherCAQH
DEP00888231Medicare PIN