Provider Demographics
NPI:1144409103
Name:ARCHIBALD, JENNIFER R (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:R
Last Name:ARCHIBALD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1069 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FALLS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:22046-4610
Mailing Address - Country:US
Mailing Address - Phone:877-230-9617
Mailing Address - Fax:
Practice Address - Street 1:1069 W BROAD ST
Practice Address - Street 2:SUITE 908
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046-4610
Practice Address - Country:US
Practice Address - Phone:877-230-9617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004222363AS0400X
MDC03660363AS0400X
MT655363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1144409103OtherBCBS
MT1144409103Medicaid
1081067OtherNCCPA
MT1144409103Medicaid