Provider Demographics
NPI:1033300538
Name:FORTUNE, JENNIFER BROOKE (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:BROOKE
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1340 N GREAT NECK RD
Mailing Address - Street 2:SUITE 1272 PMB 390
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2268
Mailing Address - Country:US
Mailing Address - Phone:757-481-5858
Mailing Address - Fax:757-481-6265
Practice Address - Street 1:1340 N GREAT NECK RD
Practice Address - Street 2:SUITE 1272 PMB 390
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2268
Practice Address - Country:US
Practice Address - Phone:757-481-5858
Practice Address - Fax:757-481-6265
Is Sole Proprietor?:No
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant