Healthcare Provider Details

I. General information

NPI: 1528552072
Provider Name (Legal Business Name): JEWEL MARIE MOREAU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 HARDEN STREET EXT STE 141
COLUMBIA SC
29203-6894
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 803-434-1433
  • Fax: 803-434-4062
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberLL52782
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number52782
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: