Provider Demographics
NPI:1396429221
Name:JARQUIN, LISSET VANESSA (PA)
Entity type:Individual
Prefix:MS
First Name:LISSET
Middle Name:VANESSA
Last Name:JARQUIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL STREET, NW, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:
Practice Address - Street 1:1860 TOWN CENTER DRIVE, SUITE 150
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5905
Practice Address - Country:US
Practice Address - Phone:703-480-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
VA0110009449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1396429221Medicaid
VA3001766998001Medicaid