Provider Demographics
NPI:1265832398
Name:STILES, JACQUELINE MICHELLE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MICHELLE
Last Name:STILES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MICHELLE
Other - Last Name:DEVAUD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13890 BRADDOCK RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2435
Mailing Address - Country:US
Mailing Address - Phone:703-830-6360
Mailing Address - Fax:703-830-6360
Practice Address - Street 1:13890 BRADDOCK RD
Practice Address - Street 2:SUITE 102
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2435
Practice Address - Country:US
Practice Address - Phone:703-830-6360
Practice Address - Fax:703-830-6360
Is Sole Proprietor?:No
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305209030225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist