Healthcare Provider Details

I. General information

NPI: 1710858410
Provider Name (Legal Business Name): JADE PHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2025
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10110 MOLECULAR DR STE 111
ROCKVILLE MD
20850-7538
US

IV. Provider business mailing address

10110 MOLECULAR DR STE 111
ROCKVILLE MD
20850-7538
US

V. Phone/Fax

Practice location:
  • Phone: 301-838-4224
  • Fax:
Mailing address:
  • Phone: 301-838-4224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0010671
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: