Healthcare Provider Details

I. General information

NPI: 1073671988
Provider Name (Legal Business Name): BEVERLY WADDELL-JIGGETTS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14139 POTOMAC MILLS ROAD
WOODBRIDGE VA
22192-4644
US

IV. Provider business mailing address

KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP 2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNIT 6 W
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 703-490-8400
  • Fax: 703-490-7701
Mailing address:
  • Phone: 301-816-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101045183
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD0071877
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD039469
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: