Healthcare Provider Details

I. General information

NPI: 1669930962
Provider Name (Legal Business Name): DR. JACQUELINE NICOLE LIU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2019
Last Update Date: 10/26/2024
Certification Date: 10/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6204 LITTLE RIVER TPKE
ALEXANDRIA VA
22312-1714
US

IV. Provider business mailing address

8190 STRAWBERRY LN APT N513
FALLS CHURCH VA
22042-1021
US

V. Phone/Fax

Practice location:
  • Phone: 703-420-1079
  • Fax:
Mailing address:
  • Phone: 203-715-8880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401418704
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: