Provider Demographics
NPI:1578551040
Name:LOULOUDES, JENNIFER (PA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:LOULOUDES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 WAKE FOREST RD STE 210
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6864
Mailing Address - Country:US
Mailing Address - Phone:919-787-7246
Mailing Address - Fax:919-787-7247
Practice Address - Street 1:3801 WAKE FOREST RD STE 210
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6864
Practice Address - Country:US
Practice Address - Phone:919-787-7246
Practice Address - Fax:919-787-7247
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09017363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q15322Medicare UPIN
MAAP2103Medicare ID - Type Unspecified