Provider Demographics
NPI:1699192492
Name:JAECQUES, SERENA (OTR/L)
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:JAECQUES
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 NEWTOWN RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1116
Mailing Address - Country:US
Mailing Address - Phone:757-473-8016
Mailing Address - Fax:
Practice Address - Street 1:818 NEWTOWN RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-1116
Practice Address - Country:US
Practice Address - Phone:757-473-8016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119000308225X00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No174400000XOther Service ProvidersSpecialist