Provider Demographics
NPI:1124874789
Name:MACIAS, JACQUELINE (PTA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MACIAS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8227 MEADOWBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23116-2322
Mailing Address - Country:US
Mailing Address - Phone:804-767-3092
Mailing Address - Fax:
Practice Address - Street 1:8227 MEADOWBRIDGE RD
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-2322
Practice Address - Country:US
Practice Address - Phone:804-767-3092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306606517225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty