Healthcare Provider Details

I. General information

NPI: 1902361454
Provider Name (Legal Business Name): JENNIFER A DALE LPC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2019
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 GADSDEN ST
COLUMBIA SC
29201-6400
US

IV. Provider business mailing address

112 IRONCREST WAY
COLUMBIA SC
29212-0607
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-9767
  • Fax:
Mailing address:
  • Phone: 803-873-1192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number7040
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: