Provider Demographics
NPI:1043854870
Name:MALHOTRA, JESSICA LOFGREN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LOFGREN
Last Name:MALHOTRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16060 OLD CASTLE RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-3593
Mailing Address - Country:US
Mailing Address - Phone:804-908-7292
Mailing Address - Fax:
Practice Address - Street 1:16060 OLD CASTLE RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-3593
Practice Address - Country:US
Practice Address - Phone:804-908-7292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0024179322367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program