MEDICARE: DR. JACQUELINE NICOLE LIU

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	1223P0221X	Pediatric Dentistry	0401418704	VA

General Provider Information

NPI Number	:	1669930962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACQUELINE NICOLE LIU

Provider Business Mailing Address
First Line	:	8190 STRAWBERRY LN APT N513
Second Line	:
City	:	FALLS CHURCH
State	:	VA
Zip	:	22042-1021
Country	:	US
Telephone Number	:	203-715-8880
Fax Number	:

Provider Business Practice Location Address
First Line	:	6204 LITTLE RIVER TPKE
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22312-1714
Country	:	US
Telephone Number	:	703-420-1079
Fax Number	:

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

Provider Enumeration Date	:	03/05/2019
Last Update Date	:	10/26/2024

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