Healthcare Provider Details

I. General information

NPI: 1205461498
Provider Name (Legal Business Name): JENNIFER LYNN BRESEMAN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2020
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1313 DOLLEY MADISON BOULEVARD, SUITE 104
MC LEAN VA
22101-3926
US

IV. Provider business mailing address

224D CORNWALL ST NW STE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-263-8282
  • Fax:
Mailing address:
  • Phone: 703-737-6010
  • Fax: 703-443-8643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024181430
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number0001150606
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: