Healthcare Provider Details

I. General information

NPI: 1982675260
Provider Name (Legal Business Name): JENNIE L KOWALESKI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 BLUE RIDGE RD STE. 103
RALEIGH NC
27612-8036
US

IV. Provider business mailing address

3100 BLUE RIDGE RD STE. 103
RALEIGH NC
27612-8036
US

V. Phone/Fax

Practice location:
  • Phone: 919-719-2250
  • Fax: 919-719-2248
Mailing address:
  • Phone: 919-719-2250
  • Fax: 919-719-2248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103546
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: