Healthcare Provider Details

I. General information

NPI: 1578322699
Provider Name (Legal Business Name): MARY HEEJOO JANG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY HEEJOO JANG PA

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14266B WOVEN WILLOW LN
CENTREVILLE VA
20121-2291
US

IV. Provider business mailing address

14266B WOVEN WILLOW LN
CENTREVILLE VA
20121-2291
US

V. Phone/Fax

Practice location:
  • Phone: 703-625-6921
  • Fax:
Mailing address:
  • Phone: 703-625-6921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110012133
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: