MEDICARE: JESSICA LA FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024185108	VA

General Provider Information

NPI Number	:	1881315125
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA LA FNP

Provider Business Mailing Address
First Line	:	5216 ELLICOTT CT
Second Line	:
City	:	CENTREVILLE
State	:	VA
Zip	:	20120-1726
Country	:	US
Telephone Number	:	703-789-4392
Fax Number	:

Provider Business Practice Location Address
First Line	:	8078 CRESCENT PARK DR STE 201
Second Line	:
City	:	GAINESVILLE
State	:	VA
Zip	:	20155-3449
Country	:	US
Telephone Number	:	703-753-4999
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2022
Last Update Date	:	09/06/2022

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