Healthcare Provider Details

I. General information

NPI: 1750065942
Provider Name (Legal Business Name): JESSICA MARIE POLUTCHKO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA BYRNE PA-C

II. Dates (important events)

Enumeration Date: 06/09/2023
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10080 SW INNOVATION WAY STE 201
PORT ST LUCIE FL
34987-2129
US

IV. Provider business mailing address

PO BOX 748817
ATLANTA GA
30374-8817
US

V. Phone/Fax

Practice location:
  • Phone: 772-345-8100
  • Fax:
Mailing address:
  • Phone: 813-286-0033
  • Fax: 813-282-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9117407
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9117407
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: