Provider Demographics
NPI:1467993139
Name:SUPERALES, JESSICA (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SUPERALES
Suffix:
Gender:F
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 N BEAUREGARD ST STE 360
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1751
Mailing Address - Country:US
Mailing Address - Phone:703-924-9004
Mailing Address - Fax:703-924-9067
Practice Address - Street 1:2000 N BEAUREGARD ST STE 360
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1751
Practice Address - Country:US
Practice Address - Phone:703-924-9004
Practice Address - Fax:703-924-9067
Is Sole Proprietor?:No
Enumeration Date:2017-03-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1040108163W00000X
VA0001231772163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse