Provider Demographics
NPI:1760134274
Name:INTRAVAIA, JACQUELINE ALICIA (PTA)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ALICIA
Last Name:INTRAVAIA
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16954 HEATHERBROOK LN
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-7495
Mailing Address - Country:US
Mailing Address - Phone:618-521-2825
Mailing Address - Fax:
Practice Address - Street 1:901 S COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-2640
Practice Address - Country:US
Practice Address - Phone:618-253-0255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160009410225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant