Provider Demographics
NPI:1316164155
Name:JASKOLKA, JESSICA BETH (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:BETH
Last Name:JASKOLKA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1606 WELLINGTON AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7747
Mailing Address - Country:US
Mailing Address - Phone:910-452-1999
Mailing Address - Fax:910-452-1883
Practice Address - Street 1:1606 WELLINGTON AVE
Practice Address - Street 2:SUITE E
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7747
Practice Address - Country:US
Practice Address - Phone:910-452-1999
Practice Address - Fax:910-452-1883
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2008-00672208000000X
WV24142208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810019099Medicaid