=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710206818
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER DEJESUS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2010
-----------------------------------------------------
Last Update Date | 01/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7611 LITTLE RIVER TPKE STE 108
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-717-7215
-----------------------------------------------------
Fax | 703-717-7216
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7611 LITTLE RIVER TPKE STE 108
-----------------------------------------------------
City | ANNANDALE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22003-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-717-7215
-----------------------------------------------------
Fax | 703-717-7216
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MAO9285100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------