Provider Demographics
NPI:1821330002
Name:M. RENEE JESPERSEN, MD PC
Entity Type:Organization
Organization Name:M. RENEE JESPERSEN, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:JESPERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-893-1111
Mailing Address - Street 1:6845 ELM ST
Mailing Address - Street 2:SUITE 708
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-6007
Mailing Address - Country:US
Mailing Address - Phone:703-893-1111
Mailing Address - Fax:
Practice Address - Street 1:6845 ELM ST
Practice Address - Street 2:SUITE 708
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-6007
Practice Address - Country:US
Practice Address - Phone:703-893-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101233956208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty