Healthcare Provider Details

I. General information

NPI: 1912022187
Provider Name (Legal Business Name): FAIRFAX FAMILY PRAC CEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 12/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 ASHTON AVENUE SUITE 101
MANASSAS VA
20109
US

IV. Provider business mailing address

PO BOX 791128
BALTIMORE MD
21279-1128
US

V. Phone/Fax

Practice location:
  • Phone: 703-257-8090
  • Fax: 703-257-7822
Mailing address:
  • Phone: 703-257-8090
  • Fax: 703-257-7822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JAMES P JENKINS
Title or Position: PRESIDENT
Credential: MD
Phone: 703-255-9100