Healthcare Provider Details

I. General information

NPI: 1447877014
Provider Name (Legal Business Name): JORDAN KAITLYN MERRELS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2020
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRISMA HEALTH MEDICAL GROUP GENERAL PSYCHIATRY 15 MEDICAL PARK, STE 141
COLUMBIA SC
29203
US

IV. Provider business mailing address

PRISMA HEALTH MEDICAL GROUP GENERAL PSYCHIATRY 15 MEDICAL PARK, STE 141
COLUMBIA SC
29203
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-1433
  • Fax: 803-434-4062
Mailing address:
  • Phone: 803-434-1433
  • Fax: 803-434-4062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLL84531
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: