MEDICARE: MRS. LEXIE CATHERINE GRIMM JACKOWSKI PA

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
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1689317596
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LEXIE CATHERINE GRIMM JACKOWSKI PA

Provider Business Mailing Address
First Line	:	13406 PERSHING ST
Second Line	:
City	:	CUMBERLAND
State	:	MD
Zip	:	21502-5312
Country	:	US
Telephone Number	:	301-471-4063
Fax Number	:

Provider Business Practice Location Address
First Line	:	1050 W INDUSTRIAL BLVD STE 17
Second Line	:
City	:	CUMBERLAND
State	:	MD
Zip	:	21502-4331
Country	:	US
Telephone Number	:	240-964-9300
Fax Number	:	240-964-9310

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

Provider Enumeration Date	:	04/18/2022
Last Update Date	:	03/20/2026

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