Provider Demographics
NPI:1164800215
Name:BERETSKY, JENNIFER S (NP-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:BERETSKY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2555 COURT DR STE 450
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2191
Mailing Address - Country:US
Mailing Address - Phone:704-671-7652
Mailing Address - Fax:704-671-7656
Practice Address - Street 1:2555 COURT DR STE 450
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:704-671-7652
Practice Address - Fax:704-671-7656
Is Sole Proprietor?:No
Enumeration Date:2015-05-09
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007938363L00000X
MDR205065363L00000X
NC237317363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730007OtherNSC