Provider Demographics
NPI:1558327676
Name:MARK, JENNIFER L (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:L
Last Name:MARK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7357
Mailing Address - Country:US
Mailing Address - Phone:540-776-4000
Mailing Address - Fax:
Practice Address - Street 1:1900 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7474
Practice Address - Country:US
Practice Address - Phone:540-772-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235026207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00403458OtherMEDICARE RAILROAD
VA010407630Medicaid
VAP00330094OtherRAILROAD MEDICARE
VAP00330094OtherMEDICARE RAILROAD
VAP00330094OtherMEDICARE RAILROAD
VAP00330094OtherMEDICARE RAILROAD
VA010407630Medicaid