Provider Demographics
NPI:1215164132
Name:MAILLEY, JACQUELINE ANN (PTA)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ANN
Last Name:MAILLEY
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 1:201 PINELAKE DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-3287
Mailing Address - Country:US
Mailing Address - Phone:252-331-2342
Mailing Address - Fax:
Practice Address - Street 1:1075 US HIGHWAY 17 S
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-7628
Practice Address - Country:US
Practice Address - Phone:252-338-3975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4152225200000X
VA2306602684225200000X
GAPTA002011225200000X
IL160002895225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant