Provider Demographics
NPI:1407747520
Name:JENDOUBI, MARIEM
Entity type:Individual
Prefix:
First Name:MARIEM
Middle Name:
Last Name:JENDOUBI
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 1:4117 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-4888
Mailing Address - Country:US
Mailing Address - Phone:540-785-8018
Mailing Address - Fax:
Practice Address - Street 1:8403 W HILDY CT
Practice Address - Street 2:
Practice Address - City:SPOTSYLVANIA
Practice Address - State:VA
Practice Address - Zip Code:22553-3623
Practice Address - Country:US
Practice Address - Phone:540-760-2717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024193956363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner