Healthcare Provider Details

I. General information

NPI: 1194238444
Provider Name (Legal Business Name): JACQUELINE A SANTIAGO PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 POINDEXTER ST STE 219
CHESAPEAKE VA
23324-2358
US

IV. Provider business mailing address

PO BOX 412307
BOSTON MA
02241-6177
US

V. Phone/Fax

Practice location:
  • Phone: 757-548-0014
  • Fax: 757-351-1930
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number293957
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305212539
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: