Provider Demographics
NPI:1376932038
Name:LOUCKS, JUSTIN PEARCE-JORDAN (PA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:PEARCE-JORDAN
Last Name:LOUCKS
Suffix:
Gender:M
Credentials:PA
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 890293
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0293
Mailing Address - Country:US
Mailing Address - Phone:866-429-1213
Mailing Address - Fax:
Practice Address - Street 1:3332 BRIDGES ST STE B
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-3296
Practice Address - Country:US
Practice Address - Phone:252-633-4461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05521363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-05521OtherNC LICENSE