MEDICARE: MS. JODI JEAN LACKEY MBA, MHA, MMSC, PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	1782	SC
2	363AS0400X	Surgical Physician Assistant	0010-01518	NC
3	363AS0400X	Surgical Physician Assistant	3097	GA
4	363AS0400X	Surgical Physician Assistant	TL1782	SC
5	363A00000X	Physician Assistant	0010-01518	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568551729
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JODI JEAN LACKEY MBA, MHA, MMSC, PA-C

Provider Business Mailing Address
First Line	:	2169 PADDLERS COVE DR
Second Line	:
City	:	CLOVER
State	:	SC
Zip	:	29710-7201
Country	:	US
Telephone Number	:	704-975-4151
Fax Number	:

Provider Business Practice Location Address
First Line	:	4100 CARMEL RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-6150
Country	:	US
Telephone Number	:	864-288-8280
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	12/22/2021

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