Provider Demographics
NPI:1508343229
Name:PAVOLKO, JESSICA RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:RAE
Last Name:PAVOLKO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5958 ASH CT
Mailing Address - Street 2:
Mailing Address - City:SLATINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:18080-3135
Mailing Address - Country:US
Mailing Address - Phone:484-695-5112
Mailing Address - Fax:
Practice Address - Street 1:1200 S CEDAR CREST BLVD
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-6202
Practice Address - Country:US
Practice Address - Phone:610-402-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant