Individual
MS. JODI JEAN LACKEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MBA, MHA, MMSC, PA-C
Contact information
Practice address
4100 CARMEL RD, CHARLOTTE, NC 28226-6150
(864) 288-8280
Mailing address
2169 PADDLERS COVE DR, CLOVER, SC 29710-7201
(704) 975-4151
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
0010-01518
NC
363A00000X
Physician Assistant
1782
SC
363AS0400X
Surgical Physician Assistant
0010-01518
NC
363AS0400X
Surgical Physician Assistant
3097
GA
363AS0400X
Surgical Physician Assistant
TL1782
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0723PA
—
SC
Enumeration date
10/12/2006
Last updated
12/22/2021
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