Healthcare Provider Details

I. General information

NPI: 1669420824
Provider Name (Legal Business Name): CARRON JETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6439 GARNERS FERRY RD
COLUMBIA SC
29209-1638
US

IV. Provider business mailing address

6439 GARNERS FERRY RD # CLC
COLUMBIA SC
29209-1638
US

V. Phone/Fax

Practice location:
  • Phone: 803-776-4000
  • Fax:
Mailing address:
  • Phone: 803-776-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: