Provider Demographics
NPI:1891801759
Name:NYREN, JACQUELINE (MPT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:NYREN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:FRUSTACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:46161 WESTLAKE DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-5871
Mailing Address - Country:US
Mailing Address - Phone:703-444-9562
Mailing Address - Fax:703-430-2124
Practice Address - Street 1:46161 WESTLAKE DR
Practice Address - Street 2:SUITE 330
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-5871
Practice Address - Country:US
Practice Address - Phone:703-444-9562
Practice Address - Fax:703-430-2124
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305006280225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA011613T13Medicare Oscar/Certification