Provider Demographics
NPI:1982675260
Name:KOWALESKI, JENNIE L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIE
Middle Name:L
Last Name:KOWALESKI
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 1:3100 BLUE RIDGE RD
Mailing Address - Street 2:STE. 103
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-8036
Mailing Address - Country:US
Mailing Address - Phone:919-719-2250
Mailing Address - Fax:919-719-2248
Practice Address - Street 1:3100 BLUE RIDGE RD
Practice Address - Street 2:STE. 103
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8036
Practice Address - Country:US
Practice Address - Phone:919-719-2250
Practice Address - Fax:919-719-2248
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103546363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC103546OtherLICENSE
NCP91948Medicare UPIN