Provider Demographics
NPI:1609029503
Name:KATZ, JACQUELYN D (MSN, FNP-C)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:D
Last Name:KATZ
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1062 ELDEN ST
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-3803
Mailing Address - Country:US
Mailing Address - Phone:703-471-7000
Mailing Address - Fax:
Practice Address - Street 1:1062 ELDEN ST
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20170-3803
Practice Address - Country:US
Practice Address - Phone:703-471-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2015-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168042363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAMC11977Medicare PIN
VA143080ZCCUMedicare PIN