MEDICARE: DR. JENNA M STEPHENS PSYD

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	103T00000X	Psychologist
2	103TC0700X	Clinical Psychologist	003564	CT
3	103TC0700X	Clinical Psychologist	1516	SC

General Provider Information

NPI Number	:	1578919387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNA M STEPHENS PSYD

Provider Business Mailing Address
First Line	:	302 RIVER OAK DR
Second Line	:
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-8293
Country	:	US
Telephone Number	:	937-475-3086
Fax Number	:

Provider Business Practice Location Address
First Line	:	222 W COLEMAN BLVD STE 214
Second Line	:
City	:	MOUNT PLEASANT
State	:	SC
Zip	:	29464-3588
Country	:	US
Telephone Number	:	843-427-3941
Fax Number	:

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

Provider Enumeration Date	:	05/11/2016
Last Update Date	:	12/11/2024

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