Provider Demographics
NPI:1255584330
Name:DICICCO, JENNIFER RENEE (DPT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RENEE
Last Name:DICICCO
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:RENEE
Other - Last Name:MANETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 BLYTHE BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5814
Mailing Address - Country:US
Mailing Address - Phone:704-304-0620
Mailing Address - Fax:704-304-0621
Practice Address - Street 1:4501 CAMERON VALLEY PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4297
Practice Address - Country:US
Practice Address - Phone:703-304-0620
Practice Address - Fax:704-304-0620
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205704225100000X
NCP127532251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist