Healthcare Provider Details

I. General information

NPI: 1689317596
Provider Name (Legal Business Name): LEXIE CATHERINE GRIMM JACKOWSKI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2022
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 W INDUSTRIAL BLVD STE 17
CUMBERLAND MD
21502-4331
US

IV. Provider business mailing address

13406 PERSHING ST
CUMBERLAND MD
21502-5312
US

V. Phone/Fax

Practice location:
  • Phone: 240-964-9300
  • Fax: 240-964-9310
Mailing address:
  • Phone: 301-471-4063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: