Provider Demographics
NPI:1710910187
Name:RUEDA, JACQUELINE (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:RUEDA
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 1:6231 RAVENWOOD CV
Mailing Address - Street 2:
Mailing Address - City:HORN LAKE
Mailing Address - State:MS
Mailing Address - Zip Code:38637-2588
Mailing Address - Country:US
Mailing Address - Phone:901-438-8799
Mailing Address - Fax:662-280-3324
Practice Address - Street 1:6231 RAVENWOOD CV
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-2588
Practice Address - Country:US
Practice Address - Phone:901-438-8799
Practice Address - Fax:662-280-3324
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist