Healthcare Provider Details

I. General information

NPI: 1689367583
Provider Name (Legal Business Name): JACQUELINE SANTRICE ALLEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6539 TWO NOTCH RD
COLUMBIA SC
29223-7463
US

IV. Provider business mailing address

176 MCSWAIN DR
WEST COLUMBIA SC
29169-4825
US

V. Phone/Fax

Practice location:
  • Phone: 803-708-0058
  • Fax: 949-948-2859
Mailing address:
  • Phone: 843-797-3636
  • Fax: 843-797-3637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number249901
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28262
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: