Healthcare Provider Details

I. General information

NPI: 1073565651
Provider Name (Legal Business Name): JACQUELINE MELISSA KAY ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 UNIVERSITY DR MS 3A5
FAIRFAX VA
22030-4422
US

IV. Provider business mailing address

16822 VIA LA COSTA
PACIFIC PALISADES CA
90272-1970
US

V. Phone/Fax

Practice location:
  • Phone: 703-993-3279
  • Fax:
Mailing address:
  • Phone: 310-230-2280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126000941
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: