Provider Demographics
NPI:1518527266
Name:PODOLAK, JESSICA MARIE (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:PODOLAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:LOVETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1420 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5160
Practice Address - Country:US
Practice Address - Phone:704-289-8427
Practice Address - Fax:704-283-5522
Is Sole Proprietor?:No
Enumeration Date:2019-06-15
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308559363L00000X
NC5020036363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner