Healthcare Provider Details

I. General information

NPI: 1619431731
Provider Name (Legal Business Name): JAQUIA COUNTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1048 WILDWOOD CENTRE DR
COLUMBIA SC
29229-8420
US

IV. Provider business mailing address

1321 MURFREESBORO PIKE STE 702
NASHVILLE TN
37217-2679
US

V. Phone/Fax

Practice location:
  • Phone: 803-999-3752
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-17-31964
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: