Provider Demographics
NPI:1659392488
Name:WANG, JEAN ELIZA (MPT)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:ELIZA
Last Name:WANG
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11240 WAPLES MILL RD
Mailing Address - Street 2:STE 403
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030
Mailing Address - Country:US
Mailing Address - Phone:703-385-4707
Mailing Address - Fax:703-691-4933
Practice Address - Street 1:3620 JOSEPH SIEWICK DR
Practice Address - Street 2:STE100A
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1756
Practice Address - Country:US
Practice Address - Phone:703-810-5227
Practice Address - Fax:703-810-5224
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2020-10-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA2305203137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA014168C95Medicare ID - Type Unspecified