Healthcare Provider Details

I. General information

NPI: 1700543717
Provider Name (Legal Business Name): JACKLYN MARIE RECTOR FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/24/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 ASHTON AVE STE 101
MANASSAS VA
20109
US

IV. Provider business mailing address

8100 ASHTON AVE STE 101
MANASSAS VA
20109-5647
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024183190
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: