Provider Demographics
NPI:1457892960
Name:WIGGINS, JACKIE (CRT)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:WIGGINS
Suffix:
Gender:F
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15000 POTOMAC TOWN PL
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-6586
Mailing Address - Country:US
Mailing Address - Phone:678-237-6150
Mailing Address - Fax:
Practice Address - Street 1:15000 POTOMAC TOWN PL
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-6586
Practice Address - Country:US
Practice Address - Phone:678-237-6150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01170079602278H0200X
VA1401181619251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedHome Health
No251E00000XAgenciesHome Health