Provider Demographics
NPI:1316954597
Name:BOHANON, JENNIFER N
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:N
Last Name:BOHANON
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:PO BOX 1115
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1115
Mailing Address - Country:US
Mailing Address - Phone:434-517-3515
Mailing Address - Fax:434-572-4549
Practice Address - Street 1:2232 WILBORN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1662
Practice Address - Country:US
Practice Address - Phone:434-572-8977
Practice Address - Fax:434-572-2510
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00167510Medicaid
VA003832H87Medicare ID - Type Unspecified
Q13420Medicare UPIN