Provider Demographics
NPI:1952656787
Name:WOLKUN, JESSICA LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:WOLKUN
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 1:264 BOYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3070
Mailing Address - Country:US
Mailing Address - Phone:973-761-0764
Mailing Address - Fax:
Practice Address - Street 1:264 BOYDEN AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3070
Practice Address - Country:US
Practice Address - Phone:973-761-0764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00287300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical