Provider Demographics
NPI:1003921008
Name:WARE, JESSICA SUPPA (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUPPA
Last Name:WARE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4401 FORD AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1467
Mailing Address - Country:US
Mailing Address - Phone:703-379-8879
Mailing Address - Fax:703-998-6821
Practice Address - Street 1:4401 FORD AVE STE 250
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1467
Practice Address - Country:US
Practice Address - Phone:703-379-8879
Practice Address - Fax:703-998-6821
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001441363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical