Provider Demographics
NPI:1609993724
Name:CANCEL-DE JESUS, CARMEN ANA (PT)
Entity Type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:ANA
Last Name:CANCEL-DE JESUS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3234 FOOTHILL ST
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-1405
Mailing Address - Country:US
Mailing Address - Phone:703-497-0507
Mailing Address - Fax:
Practice Address - Street 1:1936-B OPITZ BLVD.
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191
Practice Address - Country:US
Practice Address - Phone:703-490-1330
Practice Address - Fax:703-490-3991
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1609993724Medicare UPIN