Provider Demographics
NPI:1063963866
Name:PUSKARICH, JESSICA (NP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:PUSKARICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 E 4TH ST
Mailing Address - Street 2:SUITE 307
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3261
Mailing Address - Country:US
Mailing Address - Phone:704-333-1259
Mailing Address - Fax:704-333-0371
Practice Address - Street 1:1718 E 4TH ST
Practice Address - Street 2:SUITE 307
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3261
Practice Address - Country:US
Practice Address - Phone:704-333-1259
Practice Address - Fax:704-333-0371
Is Sole Proprietor?:No
Enumeration Date:2016-10-18
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5009032363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care