Provider Demographics
NPI:1699130286
Name:EMORY, KATELIN JACKFERT
Entity type:Individual
Prefix:
First Name:KATELIN
Middle Name:JACKFERT
Last Name:EMORY
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 1:4168 ZINNIA LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6046
Mailing Address - Country:US
Mailing Address - Phone:304-395-0444
Mailing Address - Fax:
Practice Address - Street 1:8505 ARLINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4621
Practice Address - Country:US
Practice Address - Phone:703-280-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024173156363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner