Healthcare Provider Details

I. General information

NPI: 1396208799
Provider Name (Legal Business Name): JESSICA LEE GENDERNALIK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2019
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 FAIRGROVE CHURCH RD
NEWTON NC
28658-8531
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 828-468-3980
  • Fax:
Mailing address:
  • Phone: 704-874-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number2025-01052
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: