Provider Demographics
NPI:1366727299
Name:FARRELL, JACKELYN R (PA)
Entity type:Individual
Prefix:
First Name:JACKELYN
Middle Name:R
Last Name:FARRELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JACKELYN
Other - Middle Name:R
Other - Last Name:DUTIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:20010 CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-1115
Mailing Address - Country:US
Mailing Address - Phone:240-686-2300
Mailing Address - Fax:240-686-2330
Practice Address - Street 1:7600 CARROLL AVE
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6367
Practice Address - Country:US
Practice Address - Phone:301-891-5070
Practice Address - Fax:301-891-6346
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003704363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical