Provider Demographics
NPI:1134237811
Name:IANNICCA, JACQUELINE ROSE (MSED, ATC, CSCS)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ROSE
Last Name:IANNICCA
Suffix:
Gender:F
Credentials:MSED, ATC, CSCS
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:ROSE
Other - Last Name:GAIDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED, ATC, CSCS
Mailing Address - Street 1:1241 QUARTER WAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-8511
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:SPORTS & ADOLESCENT MEDICINE
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260005282255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer