Healthcare Provider Details

I. General information

NPI: 1346805413
Provider Name (Legal Business Name): JENNIFER FICKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2019
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

IV. Provider business mailing address

9300 DEWITT LOOP
FORT BELVOIR VA
22060-5285
US

V. Phone/Fax

Practice location:
  • Phone: 571-231-2892
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101270572
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101270572
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: