Provider Demographics
NPI:1568414399
Name:AUDIBERT, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:AUDIBERT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 PARK ST SE
Mailing Address - Street 2:#100
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4609
Mailing Address - Country:US
Mailing Address - Phone:703-591-1280
Mailing Address - Fax:703-591-1445
Practice Address - Street 1:130 PARK ST SE
Practice Address - Street 2:#100
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180-4609
Practice Address - Country:US
Practice Address - Phone:703-591-1280
Practice Address - Fax:703-591-1445
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024153157363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC006999C42Medicare PIN
VAP28964Medicare UPIN