Healthcare Provider Details

I. General information

NPI: 1588700397
Provider Name (Legal Business Name): JACQUELINE THERESA LEGETTE M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE THERESA BOSTICK

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 COLONIAL DR NETWORK PROGRAM
COLUMBIA SC
29203-6827
US

IV. Provider business mailing address

1340 LONGCREEK DR APT. 1006
COLUMBIA SC
29210-7182
US

V. Phone/Fax

Practice location:
  • Phone: 803-898-1555
  • Fax: 803-898-2194
Mailing address:
  • Phone: 803-750-5026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: