Healthcare Provider Details

I. General information

NPI: 1649812090
Provider Name (Legal Business Name): JENNA LEE BARRACLOUGH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2019
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 TAVERN RD STE 102
MARTINSBURG WV
25401-2801
US

IV. Provider business mailing address

220 CAMPUS BLVD STE 320
WINCHESTER VA
22601-2889
US

V. Phone/Fax

Practice location:
  • Phone: 304-263-5129
  • Fax: 304-263-3726
Mailing address:
  • Phone: 540-536-5100
  • Fax: 540-536-0235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number57130
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1013
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009982
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: