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General NPI Number Information
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NPI Number | 1255584330
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Entity Type | Individual
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Provider Name | JENNIFER RENEE DICICCO DPT
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Gender | Female
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Dates
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Enumeration Date | 11/03/2008
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Last Update Date | 11/05/2012
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Provider Practice Location Address
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Address Line | 4501 CAMERON VALLEY PKWY SUITE 300
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City | CHARLOTTE
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State | NC
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Zip | 28211-4297
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Country | US
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Telephone | 703-304-0620
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Fax | 704-304-0620
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Provider Business Mailing Address
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Address Line | 1100 BLYTHE BLVD
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City | CHARLOTTE
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State | NC
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Zip | 28203-5814
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Country | US
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Telephone | 704-304-0620
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Fax | 704-304-0621
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2305205704
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | P12753
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License Number State | NC
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