Healthcare Provider Details

I. General information

NPI: 1730966581
Provider Name (Legal Business Name): NICOLE JAQUETTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 N WILLIAMSBURG COUNTY HWY
CADES SC
29518-3008
US

IV. Provider business mailing address

PO BOX 23321
NEW YORK NY
10087-4321
US

V. Phone/Fax

Practice location:
  • Phone: 843-210-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9118384
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1210384
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: