Healthcare Provider Details

I. General information

NPI: 1992992382
Provider Name (Legal Business Name): JESSICA MASON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA WACKOWSKI PA

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 07/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24805 PINEBROOK RD SUITE 105
CHANTILLY VA
20152-4126
US

IV. Provider business mailing address

24805 PINEBROOK RD SUITE 105
CHANTILLY VA
20152-4126
US

V. Phone/Fax

Practice location:
  • Phone: 703-327-3173
  • Fax: 703-327-1743
Mailing address:
  • Phone: 703-327-3173
  • Fax: 703-327-1743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA053123
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110004233
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: