Provider Demographics
NPI:1568638229
Name:PEDICANO, JENNIFER BISCHOFF (MD)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:BISCHOFF
Last Name:PEDICANO
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:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:100 ELDEN ST STE 10
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-4833
Practice Address - Country:US
Practice Address - Phone:703-689-2000
Practice Address - Fax:703-478-6612
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246807207K00000X
DCMD210011988207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1568638229Medicaid
VA6M5932OtherMEDICARE PTAN