Provider Demographics
NPI:1063545655
Name:HOANG, JACQUELINE KIM (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KIM
Last Name:HOANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 BACKLICK RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22151-3904
Mailing Address - Country:US
Mailing Address - Phone:703-642-8306
Mailing Address - Fax:703-642-8342
Practice Address - Street 1:5502 BACKLICK RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22151-3904
Practice Address - Country:US
Practice Address - Phone:703-642-8306
Practice Address - Fax:703-642-8342
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053611208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006727085Medicaid
VAG43239Medicare UPIN