Healthcare Provider Details

I. General information

NPI: 1700449964
Provider Name (Legal Business Name): NICOLE D JENNINGS HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2019
Last Update Date: 04/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 SAINT ANDREWS RD STE 2&3
COLUMBIA SC
29210-5816
US

IV. Provider business mailing address

5 TROTTER CT
LUGOFF SC
29078-8734
US

V. Phone/Fax

Practice location:
  • Phone: 803-312-4850
  • Fax:
Mailing address:
  • Phone: 803-312-4850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: