Provider Demographics
NPI:1285899658
Name:JACO, LEE ANN HARTLEY (PA-C)
Entity type:Individual
Prefix:
First Name:LEE ANN
Middle Name:HARTLEY
Last Name:JACO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LEEANN
Other - Last Name:HARTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:613 E ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-5124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:613 E ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5124
Practice Address - Country:US
Practice Address - Phone:704-283-8193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01676363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1285899658Medicaid
FL000315300Medicaid
SC2818PAMedicaid
SC2818PAMedicaid
FL000315300Medicaid
NC1285899658Medicaid
NC2759380Medicare PIN
FLAL566ZMedicare PIN
NCNC2611CMedicare PIN
NCNC2611EMedicare PIN