Healthcare Provider Details

I. General information

NPI: 1245779776
Provider Name (Legal Business Name): JENNA M. ALLY MSN, AG-ACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA LOGAN

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 LEE ST
CHARLOTTESVILLE VA
22908-0001
US

IV. Provider business mailing address

PO BOX 9007
CHARLOTTESVILLE VA
22906-9007
US

V. Phone/Fax

Practice location:
  • Phone: 800-223-9173
  • Fax: 434-243-6086
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0024174559
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: