Provider Demographics
NPI:1528249133
Name:PRUITT, JENNY M (PA)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:M
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:58 CARROLL ST
Mailing Address - Street 2:ROOM 2037
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266
Mailing Address - Country:US
Mailing Address - Phone:276-883-8062
Mailing Address - Fax:276-883-8064
Practice Address - Street 1:58 CARROLL ST
Practice Address - Street 2:ROOM 2037
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-883-8062
Practice Address - Fax:276-883-8064
Is Sole Proprietor?:No
Enumeration Date:2007-11-26
Last Update Date:2017-02-23
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Provider Licenses
StateLicense IDTaxonomies
VA0110002659363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ013872Medicaid
VA1528249133Medicaid
TNQ013872Medicaid