Provider Demographics
NPI:1043971047
Name:HENRY, IAN JACOB
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:JACOB
Last Name:HENRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 FORT EVANS RD SE APT A
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20175-4142
Mailing Address - Country:US
Mailing Address - Phone:703-371-4437
Mailing Address - Fax:
Practice Address - Street 1:1850 TOWN CENTER PKWY
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-3298
Practice Address - Country:US
Practice Address - Phone:703-689-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-03
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical