Provider Demographics
NPI:1013977545
Name:CADDY, JACLYN M (MPT)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:CADDY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:771 PILOT HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:9 MANHATTAN SQUARE
Practice Address - Street 2:STE B
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666
Practice Address - Country:US
Practice Address - Phone:757-825-3400
Practice Address - Fax:757-825-0392
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204255225100000X
PADAPT000324225100000X
PAPT015366225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA007949T54Medicare ID - Type Unspecified
Q48260Medicare UPIN