Healthcare Provider Details

I. General information

NPI: 1518777010
Provider Name (Legal Business Name): JAVON JENNINGS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 JOSEPH SIEWICK DR STE 302
FAIRFAX VA
22033-1739
US

IV. Provider business mailing address

151 SOUTHHALL LN # 500
MAITLAND FL
32751-7176
US

V. Phone/Fax

Practice location:
  • Phone: 703-648-2488
  • Fax: 703-648-2489
Mailing address:
  • Phone: 703-648-2488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110011355
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: