Provider Demographics
NPI:1134722002
Name:MARDEN, JEAN
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:MARDEN
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 1:11111 LAKE CHAPEL LN
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-4301
Mailing Address - Country:US
Mailing Address - Phone:703-758-9455
Mailing Address - Fax:
Practice Address - Street 1:12027 TOWN SQUARE ST
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-6025
Practice Address - Country:US
Practice Address - Phone:703-707-9787
Practice Address - Fax:703-707-9845
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202006195183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist