Healthcare Provider Details

I. General information

NPI: 1235055138
Provider Name (Legal Business Name): JESSICA ALLEN SKINNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2625 RUTLEDGE ST
COLUMBIA SC
29204-2520
US

IV. Provider business mailing address

104 BEAUMONT PARK CIR
BLYTHEWOOD SC
29016-8276
US

V. Phone/Fax

Practice location:
  • Phone: 864-979-8600
  • Fax:
Mailing address:
  • Phone: 864-979-8600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: