Basic Information
| Provider Information | |||||||||
| NPI: | 1255455630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HORNER | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | RENA | ||||||||
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| Credential: | COTA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | HOLDEN | ||||||||
| OtherFirstName: | JACQUELINE | ||||||||
| OtherMiddleName: | RENA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 518 PLEASANTS DR. | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5408987163 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11 DAIRY LANE | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403719414 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 1021124 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.