Healthcare Provider Details

I. General information

NPI: 1902139652
Provider Name (Legal Business Name): LINDA DAWN JENNESS-MCCLELLAN PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 CONGRESS RD
EASTOVER SC
29044-9165
US

IV. Provider business mailing address

1109 CONGRESS RD
EASTOVER SC
29044-9165
US

V. Phone/Fax

Practice location:
  • Phone: 803-783-8000
  • Fax:
Mailing address:
  • Phone: 803-783-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number834
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: