MEDICARE: JACQUELINE A SANTIAGO PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	293957	CA
2	225100000X	Physical Therapist	2305212539	VA

General Provider Information

NPI Number	:	1194238444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE A SANTIAGO PT, DPT

Provider Business Mailing Address
First Line	:	PO BOX 412307
Second Line	:
City	:	BOSTON
State	:	MA
Zip	:	02241-6177
Country	:	US
Telephone Number	:	914-294-4050
Fax Number	:	631-760-8306

Provider Business Practice Location Address
First Line	:	801 POINDEXTER ST STE 219
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23324-2358
Country	:	US
Telephone Number	:	757-548-0014
Fax Number	:	757-351-1930

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2017
Last Update Date	:	06/23/2021

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