Provider Demographics
NPI:1124025077
Name:CORRY, JACQUELINE JOANNE (DPT)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:JOANNE
Last Name:CORRY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8575 RIXLEW LN
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-3701
Mailing Address - Country:US
Mailing Address - Phone:703-257-9770
Mailing Address - Fax:703-257-2937
Practice Address - Street 1:8575 RIXLEW LN
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-3701
Practice Address - Country:US
Practice Address - Phone:703-257-9770
Practice Address - Fax:703-257-2937
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00009564225100000X
UT3777512401225100000X
VA2305206779225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9171COOtherREGENCE BLUESHIELD
WA292104132OtherTRICARE
WA0190045OtherDEPT. LABOR & INDUSTRIES
WA8422248Medicaid
WA9171COOtherREGENCE BLUESHIELD
WA8808331Medicare ID - Type Unspecified