Healthcare Provider Details

I. General information

NPI: 1144409103
Provider Name (Legal Business Name): JENNIFER R ARCHIBALD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 05/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 W BROAD ST SUITE 908
FALLS CHURCH VA
22046-4610
US

IV. Provider business mailing address

1069 W BROAD ST
FALLS CHURCH VA
22046-4610
US

V. Phone/Fax

Practice location:
  • Phone: 877-230-9617
  • Fax:
Mailing address:
  • Phone: 877-230-9617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110004222
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC03660
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number655
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: