NPIMap

Individual provider Active NPI

Jenny M Pruitt, PA

  • Medical Physician Assistant
  • Lebanon, VA
National Provider Identifier
1528249133
Registry record updated Feb 23, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
License
0110002659 Issued in VA
Practice address
58 Carroll St
Room 2037
Lebanon, VA 24266
Phone
(276) 883-8062
Fax
(276) 883-8064
NPI assigned
Nov 26, 2007
Last updated
Feb 23, 2017By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 23, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X 0110002659 VA Primary

Addresses

Primary practice location

58 Carroll St
Room 2037
Lebanon, VA 24266

Mailing address

58 Carroll St
Room 2037
Lebanon, VA 24266
Phone (276) 883-8062

Other identifiers 2

IdentifierTypeStateIssuer
1528249133MedicaidVA
Q013872MedicaidTN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20080211000842 VA Practitioner - Physician Assistant 3173606365 Reassigns benefits to 5 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2007
Medicare assignment
May accept Medicare assignment
Telehealth
Offers telehealth services
Group practices
Clyburn Physician Services LLCGroup PAC ID 9335631100, 20 clinicians
Benham Physician Services LLCGroup PAC ID 5496248353, 10 clinicians

Practice addresses (Care Compare)

245 Medical Park Dr
Marion, VA 24354-1100
Phone (276) 378-1000

323 Falls NWDR
Abingdon, VA 24210-8093
Phone (276) 628-2612

58 Carrol St
Lebanon, VA 24266
Phone (276) 883-8000

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
0110002659VAMDMedical Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Blue Ridge Medical Management Corporation CurrentSince Jul 13, 2015 Accepting new patients
Wellmont Medical Associates, Inc. CurrentSince May 1, 2021 Accepting new patients
Wellmont Medical Associates, Inc. CurrentSince May 1, 2021 Accepting new patients
Clyburn Physician Services LLC CurrentSince Nov 20, 2025 Accepting new patients
Benham Physician Services LLC CurrentSince Nov 20, 2025 Accepting new patients
Oxbow Physician Services LLC CurrentSince Nov 3, 2025 Accepting new patients
Blue Ridge Medical Management Corporation CurrentSince Jul 13, 2015 Accepting new patients
Blue Ridge Medical Managment Corporation Past Accepting new patients

Locations

16000 Johnston Memorial Dr
Abingdon, VA 24211
Phone (276) 258-1000

323 Falls Dr NW
Abingdon, VA 24210
Phone (276) 628-2612

391 Falls Dr NW
Abingdon, VA 24210
Phone (276) 628-4406

1990 Holton Ave E
Big Stone Gap, VA 24219
Phone (276) 523-3111

245 Medical Park Dr
Marion, VA 24354
Phone (276) 378-1000

Organizations & group practices 10

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1196035200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1487808000000",
    "number": "1528249133",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "58 CARROLL ST",
            "address_2": "ROOM 2037",
            "city": "LEBANON",
            "state": "VA",
            "postal_code": "24266",
            "telephone_number": "276-883-8062",
            "fax_number": "276-883-8064"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "58 CARROLL ST",
            "address_2": "ROOM 2037",
            "city": "LEBANON",
            "state": "VA",
            "postal_code": "24266",
            "telephone_number": "276-883-8062",
            "fax_number": "276-883-8064"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "PRUITT",
        "first_name": "JENNY",
        "middle_name": "M",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2007-11-26",
        "last_updated": "2017-02-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "VA",
            "license": "0110002659",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1528249133",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "Q013872",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Lebanon, VA

Sources for this page

Verify at the official NPI Registry.