Provider Demographics
NPI:1992992382
Name:MASON, JESSICA (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MASON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WACKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:24805 PINEBROOK RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20152-4126
Mailing Address - Country:US
Mailing Address - Phone:703-327-3173
Mailing Address - Fax:703-327-1743
Practice Address - Street 1:24805 PINEBROOK RD
Practice Address - Street 2:SUITE 105
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20152-4126
Practice Address - Country:US
Practice Address - Phone:703-327-3173
Practice Address - Fax:703-327-1743
Is Sole Proprietor?:No
Enumeration Date:2007-09-28
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053123363AM0700X
VA0110004233363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVVA837AMedicare PIN