Provider Demographics
NPI:1679972749
Name:MUNDUS, JACQUELINE BOURASSA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:BOURASSA
Last Name:MUNDUS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:JACQUELINE
Other - Middle Name:MARIE
Other - Last Name:BOURASSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1525 WILSON BLVD STE 125
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22209-2470
Mailing Address - Country:US
Mailing Address - Phone:703-966-7127
Mailing Address - Fax:
Practice Address - Street 1:50 IRVING ST NW
Practice Address - Street 2:DERMATOLOGY DEPARTMENT - VAMC
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20422-0001
Practice Address - Country:US
Practice Address - Phone:202-745-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005468363A00000X
VA0110004669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant