Healthcare Provider Details

I. General information

NPI: 1013372283
Provider Name (Legal Business Name): JACQUELINE DANG TRUONG PT, DPT, OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2015
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15476B DEDEAUX RD
GULFPORT MS
39503-2637
US

IV. Provider business mailing address

42465 HIGHWAY 195
HALEYVILLE AL
35565-7052
US

V. Phone/Fax

Practice location:
  • Phone: 228-539-3232
  • Fax: 228-539-3230
Mailing address:
  • Phone: 256-350-1764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number1290020
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number42831
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number42831
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7648
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: