Healthcare Provider Details

I. General information

NPI: 1124318415
Provider Name (Legal Business Name): KRISTIN PUPA JACONO DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 BANK ST
CHESAPEAKE CITY MD
21915-1016
US

IV. Provider business mailing address

227 BANK ST
CHESAPEAKE CITY MD
21915-1016
US

V. Phone/Fax

Practice location:
  • Phone: 410-392-2731
  • Fax: 410-392-2732
Mailing address:
  • Phone: 410-392-2731
  • Fax: 410-392-2732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6227
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305206860
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number23775
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: