Basic Information
| Provider Information | |||||||||
| NPI: | 1013977545 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CADDY | ||||||||
| FirstName: | JACLYN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 771 PILOT HOUSE DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578732302 | ||||||||
| FaxNumber: | 7578732306 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 MANHATTAN SQUARE | ||||||||
| Address2: | STE B | ||||||||
| City: | HAMPTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7578253400 | ||||||||
| FaxNumber: | 7578250392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2305204255 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | DAPT000324 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT015366 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.