Provider Demographics
NPI:1720451321
Name:JAFFE, STACY MARIE (OD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:JAFFE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:MARIE
Other - Last Name:FORTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:42015 VILLAGE PLZ
Practice Address - Street 2:STE 103
Practice Address - City:STONE RIDGE
Practice Address - State:VA
Practice Address - Zip Code:20105
Practice Address - Country:US
Practice Address - Phone:703-542-8888
Practice Address - Fax:703-542-8856
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618002441152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist