Provider Demographics
NPI:1356010631
Name:VANCE, JACQUELINE MAY
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MAY
Last Name:VANCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6218 ERMAN ST
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-3516
Mailing Address - Country:US
Mailing Address - Phone:703-568-4844
Mailing Address - Fax:
Practice Address - Street 1:4850 31ST ST S STE B
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22206-1661
Practice Address - Country:US
Practice Address - Phone:703-527-8446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206929225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist