Provider Demographics
NPI:1366769044
Name:DEANE-WYMAN, JESSICA JAMESON (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:JAMESON
Last Name:DEANE-WYMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:J
Other - Last Name:DEANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-3000
Mailing Address - Fax:704-316-3001
Practice Address - Street 1:2100 S TRYON ST
Practice Address - Street 2:STE 201
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4958
Practice Address - Country:US
Practice Address - Phone:704-316-3000
Practice Address - Fax:704-316-3001
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC164466207V00000X
NC2014-00173207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1366769044Medicaid
SCNC2198Medicaid
SCNC2198Medicaid