Provider Demographics
NPI:1396183604
Name:BRAGA, JACQUELINE DIANE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DIANE
Last Name:BRAGA
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 1:111 RENEGAR WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-8840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 RENEGAR WAY
Practice Address - Street 2:
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-8840
Practice Address - Country:US
Practice Address - Phone:912-219-2029
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-08
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6547225100000X
GAPT011520225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist