Healthcare Provider Details

I. General information

NPI: 1467472407
Provider Name (Legal Business Name): JACQUELYN B FREEMAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 CRESTVIEW RD
EASLEY SC
29642-2408
US

IV. Provider business mailing address

1351 CRESTVIEW RD
EASLEY SC
29642-2408
US

V. Phone/Fax

Practice location:
  • Phone: 864-855-5006
  • Fax: 864-850-1992
Mailing address:
  • Phone: 864-855-5006
  • Fax: 864-850-1992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberAPN2404
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierNP0194
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: