Healthcare Provider Details

I. General information

NPI: 1629503594
Provider Name (Legal Business Name): JENNIFER JUNIOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2170 WALKER SOLOMON WAY
COLUMBIA SC
29204-1130
US

IV. Provider business mailing address

2170 WALKER SOLOMON WAY
COLUMBIA SC
29204-1130
US

V. Phone/Fax

Practice location:
  • Phone: 803-600-8776
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number20945
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number20945
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number20945
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: