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General NPI Number Information
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NPI Number | 1457892960
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Entity Type | Individual
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Provider Name | JACKIE WIGGINS CRT
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Gender | Female
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Dates
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Enumeration Date | 03/16/2017
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Last Update Date | 03/16/2017
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Provider Practice Location Address
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Address Line | 15000 POTOMAC TOWN PL
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City | WOODBRIDGE
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State | VA
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Zip | 22191-6586
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Country | US
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Telephone | 678-237-6150
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Fax |
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Provider Business Mailing Address
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Address Line | 15000 POTOMAC TOWN PL
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City | WOODBRIDGE
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State | VA
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Zip | 22191-6586
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Country | US
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Telephone | 678-237-6150
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Fax |
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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 | 2278H0200X
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Taxonomy Name | Home Health Certified Respiratory Therapist
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License Number | 0117007960
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 1401181619
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License Number State | VA
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