Provider Demographics
NPI:1568551729
Name:LACKEY, JODI JEAN (MBA, MHA, MMSC, PA-C)
Entity Type:Individual
Prefix:MS
First Name:JODI
Middle Name:JEAN
Last Name:LACKEY
Suffix:
Gender:F
Credentials:MBA, MHA, MMSC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2169 PADDLERS COVE DR
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-7201
Mailing Address - Country:US
Mailing Address - Phone:704-975-4151
Mailing Address - Fax:
Practice Address - Street 1:4100 CARMEL RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-6150
Practice Address - Country:US
Practice Address - Phone:864-288-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1782363A00000X
NC0010-01518363AS0400X, 363A00000X
GA3097363AS0400X
SCTL1782363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0723PAMedicaid
NC2759259Medicare PIN
NC2759259AMedicare PIN
NC2759259BMedicare PIN