Healthcare Provider Details

I. General information

NPI: 1528819802
Provider Name (Legal Business Name): JESSICA TAYLOR KROGH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3241 WESTERN BRANCH BLVD
CHESAPEAKE VA
23321-5260
US

IV. Provider business mailing address

7320 CARLTON ARMS DR APT A
NEW PORT RICHEY FL
34653-6817
US

V. Phone/Fax

Practice location:
  • Phone: 727-686-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110012087
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: