Healthcare Provider Details

I. General information

NPI: 1164800215
Provider Name (Legal Business Name): JENNIFER S. BERETSKY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2015
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 COURT DR STE 450
GASTONIA NC
28054
US

IV. Provider business mailing address

2555 COURT DR STE 450
GASTONIA NC
28054-2191
US

V. Phone/Fax

Practice location:
  • Phone: 704-671-7652
  • Fax: 704-671-7656
Mailing address:
  • Phone: 704-671-7652
  • Fax: 704-671-7656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5007938
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR205065
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number237317
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: