Healthcare Provider Details

I. General information

NPI: 1710060330
Provider Name (Legal Business Name): FAIRFAX FAMILY PRACTICE CENTERS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 02/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 CENTREVILLE RD STE 100
CENTREVILLE VA
20121-2626
US

IV. Provider business mailing address

PO BOX 791128
BALTIMORE MD
21279-1128
US

V. Phone/Fax

Practice location:
  • Phone: 703-263-9600
  • Fax: 703-266-1452
Mailing address:
  • Phone: 703-391-2030
  • Fax: 703-273-3943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number0631926
License Number StateVA

VIII. Authorized Official

Name: DR. JAMES P. JENKINS JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 703-391-2030