Provider Demographics
NPI:1255123345
Name:DERIVERA, JENNA ELIZ TAN (CAA)
Entity type:Individual
Prefix:
First Name:JENNA ELIZ
Middle Name:TAN
Last Name:DERIVERA
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2300 M ST NW FL 7
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-1434
Mailing Address - Country:US
Mailing Address - Phone:202-823-4220
Mailing Address - Fax:202-823-4221
Practice Address - Street 1:1200 PECAN ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-2652
Practice Address - Country:US
Practice Address - Phone:202-823-4220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-22
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant