Healthcare Provider Details

I. General information

NPI: 1821330002
Provider Name (Legal Business Name): M. RENEE JESPERSEN, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2013
Last Update Date: 03/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6845 ELM ST SUITE 708
MC LEAN VA
22101-6007
US

IV. Provider business mailing address

6845 ELM ST SUITE 708
MC LEAN VA
22101-6007
US

V. Phone/Fax

Practice location:
  • Phone: 703-893-1111
  • Fax:
Mailing address:
  • Phone: 703-893-1111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0101233956
License Number StateVA

VIII. Authorized Official

Name: MARSHA RENEE JESPERSEN
Title or Position: OWNER
Credential: MD
Phone: 703-893-1111