Provider Demographics
NPI:1376562108
Name:JERVIS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JERVIS
Suffix:
Gender:F
Credentials:
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 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:980-302-6380
Mailing Address - Fax:980-302-6385
Practice Address - Street 1:125 QUEENS RD STE 500
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3215
Practice Address - Country:US
Practice Address - Phone:980-302-6380
Practice Address - Fax:980-302-6385
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900072207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1218LOtherBLUE CROSS BLUE SHIELD
NC1376562108Medicaid
NC891218LMedicaid
G-94784Medicare UPIN
NC891218LMedicaid