Provider Demographics
NPI:1699120733
Name:STEVENSON, JESSICA IVY (PA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:IVY
Last Name:STEVENSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3320 ROBINWOOD RD
Practice Address - Street 2:STE 100
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-6689
Practice Address - Country:US
Practice Address - Phone:980-487-2930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant