Provider Demographics
NPI:1205135159
Name:JACQUES, LAUREN CASSIS (PA-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:CASSIS
Last Name:JACQUES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:LEE
Other - Last Name:CASSIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:98 ALEXANDRIA PIKE,
Mailing Address - Street 2:SUITE 52
Mailing Address - City:WARRENTON
Mailing Address - State:VA
Mailing Address - Zip Code:20186
Mailing Address - Country:US
Mailing Address - Phone:540-905-7456
Mailing Address - Fax:
Practice Address - Street 1:98 ALEXANDRIA PIKE,
Practice Address - Street 2:SUITE 52
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186
Practice Address - Country:US
Practice Address - Phone:540-905-7456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-17
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003420363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1205135159Medicaid