Provider Demographics
NPI:1629847397
Name:CANAVAN, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7051 HEATHCOTE VILLAGE WAY STE 230
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3266
Mailing Address - Country:US
Mailing Address - Phone:571-472-4200
Mailing Address - Fax:703-279-4201
Practice Address - Street 1:7051 HEATHCOTE VILLAGE WAY STE 230
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3266
Practice Address - Country:US
Practice Address - Phone:571-472-4200
Practice Address - Fax:703-279-4201
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2025-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017807210001Medicaid