Provider Demographics
NPI:1598277790
Name:BUSHAW, JENNA (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BUSHAW
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 1:811 REDGATE AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1515
Mailing Address - Country:US
Mailing Address - Phone:757-668-7007
Mailing Address - Fax:757-668-8658
Practice Address - Street 1:3960 VIRGINIA BEACH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-2449
Practice Address - Country:US
Practice Address - Phone:757-668-4648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006594363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant