MEDICARE: JANA ISOM

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	103TS0200X	School Psychologist	222790	SC

General Provider Information

NPI Number	:	1063946309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANA ISOM

Provider Business Mailing Address
First Line	:	7301 RIVERS AVE
Second Line	:	SUITE 100
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-4650
Country	:	US
Telephone Number	:	843-637-4211
Fax Number	:

Provider Business Practice Location Address
First Line	:	7301 RIVERS AVE
Second Line	:	SUITE 100
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-4650
Country	:	US
Telephone Number	:	843-637-4211
Fax Number	:

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

Provider Enumeration Date	:	04/13/2017
Last Update Date	:	04/13/2017

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Directions to “ JANA ISOM ” Practice Location

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