Healthcare Provider Details

I. General information

NPI: 1396429221
Provider Name (Legal Business Name): LISSET VANESSA JARQUIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 TOWN CENTER DRIVE, SUITE 150
RESTON VA
20190-5905
US

IV. Provider business mailing address

224-D CORNWALL STREET, NW, SUITE 403
LEESBURG VA
20176-2704
US

V. Phone/Fax

Practice location:
  • Phone: 703-480-0220
  • Fax:
Mailing address:
  • Phone: 703-737-6010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110009449
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: