Provider Demographics
NPI:1629132576
Name:JEDLICA, MICHELE TERESA
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:TERESA
Last Name:JEDLICA
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 1:404 WESTWOOD AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4315
Mailing Address - Country:US
Mailing Address - Phone:336-889-6564
Mailing Address - Fax:336-889-5252
Practice Address - Street 1:404 WESTWOOD AVE
Practice Address - Street 2:STE 103
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4315
Practice Address - Country:US
Practice Address - Phone:336-889-6564
Practice Address - Fax:336-889-5252
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901213208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126WYMedicaid
NC89126WYMedicaid