Provider Demographics
NPI:1073183828
Name:LOBUE, JACLYN
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:LOBUE
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 1:2722 MERRILEE DR
Mailing Address - Street 2:STE 230
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4400
Mailing Address - Country:US
Mailing Address - Phone:703-698-4444
Mailing Address - Fax:
Practice Address - Street 1:8505 ARLINGTON BLVD STE 400
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4636
Practice Address - Country:US
Practice Address - Phone:703-698-4475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-24
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024181610363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner