Provider Demographics
NPI:1184932568
Name:KOVALCHICK, JESSICA S (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:S
Last Name:KOVALCHICK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:S
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:105 RIDGEHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-2640
Mailing Address - Country:US
Mailing Address - Phone:607-798-6176
Mailing Address - Fax:
Practice Address - Street 1:105 RIDGEHAVEN DR
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2640
Practice Address - Country:US
Practice Address - Phone:607-798-6176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-19
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054574363AM0700X
NY017256363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical