Healthcare Provider Details

I. General information

NPI: 1407824394
Provider Name (Legal Business Name): JACQUELINE JIANG FREDRICK OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5511 MERCHANTS VIEW SQ
HAYMARKET VA
20169-5439
US

IV. Provider business mailing address

5511 MERCHANTS VIEW SQ
HAYMARKET VA
20169-5439
US

V. Phone/Fax

Practice location:
  • Phone: 703-659-4430
  • Fax: 703-659-4438
Mailing address:
  • Phone: 703-659-4430
  • Fax: 703-273-0239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618001433
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: