Basic Information
| Provider Information | |||||||||
| NPI: | 1881315125 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LA | ||||||||
| FirstName: | JESSICA | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5216 ELLICOTT CT | ||||||||
| Address2: | |||||||||
| City: | CENTREVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201201726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037894392 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8078 CRESCENT PARK DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 201553449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037534999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2022 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024185108 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.