Healthcare Provider Details

I. General information

NPI: 1922450238
Provider Name (Legal Business Name): JESSICA P BAUCOM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CHURCH ST N
CONCORD NC
28025
US

IV. Provider business mailing address

700 E MOREHEAD ST STE 300
CHARLOTTE NC
28202-2742
US

V. Phone/Fax

Practice location:
  • Phone: 704-403-1430
  • Fax: 704-403-1158
Mailing address:
  • Phone: 704-362-5391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number224080
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: