Healthcare Provider Details

I. General information

NPI: 1912365347
Provider Name (Legal Business Name): JENNIFER YEALY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2016
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEMORIAL DR
LURAY VA
22835
US

IV. Provider business mailing address

PO BOX 3777
PORTLAND OR
97208-3777
US

V. Phone/Fax

Practice location:
  • Phone: 540-743-4561
  • Fax:
Mailing address:
  • Phone: 503-413-3900
  • Fax: 503-413-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110005197
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA187741
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: