Healthcare Provider Details

I. General information

NPI: 1093555716
Provider Name (Legal Business Name): JENNA VIDITZ-WARD AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNA M VAN BOSCH AU.D.

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 GOLD HILL RD STE 104
FORT MILL SC
29708-8988
US

IV. Provider business mailing address

870 GOLD HILL RD STE 104
FORT MILL SC
29708-8988
US

V. Phone/Fax

Practice location:
  • Phone: 803-620-8250
  • Fax: 803-638-6901
Mailing address:
  • Phone: 803-620-8250
  • Fax: 803-638-6901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number7971
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number7971
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: