Healthcare Provider Details

I. General information

NPI: 1164307757
Provider Name (Legal Business Name): JEZZICA AVRYL NODALO AVANCENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 GREGG HWY NW
AIKEN SC
29801-6341
US

IV. Provider business mailing address

1135 GREGG HWY NW
AIKEN SC
29801-6341
US

V. Phone/Fax

Practice location:
  • Phone: 803-641-7700
  • Fax:
Mailing address:
  • Phone: 803-641-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: