Provider Demographics
NPI:1982043188
Name:FEDORKA, JESSICA (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FEDORKA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:521 MOUNT HOPE ST STE 206H
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-2611
Mailing Address - Country:US
Mailing Address - Phone:774-643-0505
Mailing Address - Fax:774-214-0050
Practice Address - Street 1:521 MOUNT HOPE ST STE 206H
Practice Address - Street 2:
Practice Address - City:NORTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02760-2611
Practice Address - Country:US
Practice Address - Phone:774-643-0505
Practice Address - Fax:774-214-0050
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4674363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA045351275OtherTAX EIN