Healthcare Provider Details

I. General information

NPI: 1962833798
Provider Name (Legal Business Name): JEANETTE FORREST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2013
Last Update Date: 03/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 RICHLAND MEDICAL PARK DR SUITE 400
COLUMBIA SC
29203-8005
US

IV. Provider business mailing address

PO BOX 743904
ATLANTA GA
30374-3904
US

V. Phone/Fax

Practice location:
  • Phone: 803-765-0871
  • Fax: 803-765-9215
Mailing address:
  • Phone: 803-296-7320
  • Fax: 803-296-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18545
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: