Provider Demographics
NPI:1275562571
Name:STATIS, JENNIFER (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:STATIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6025 BLAKENEY PARK DR
Practice Address - Street 2:STE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-5703
Practice Address - Country:US
Practice Address - Phone:704-667-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00781208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1275562571Medicaid
NC5903746Medicaid
SCNC2834Medicaid
NC1427KOtherBCBS
NC9349094OtherCIGNA HEALTH CARE
NC7129824OtherAETNA
NC190888OtherMEDCOST
NC566000156OtherPRACTICE TAX ID
NC808094OtherPARTNERS MEDICARE CHOICE
NCNCT869BMedicare PIN
NC5903746Medicaid
NC9349094OtherCIGNA HEALTH CARE
NCNCT869DMedicare PIN
NCNCT869CMedicare PIN