Healthcare Provider Details

I. General information

NPI: 1518512029
Provider Name (Legal Business Name): JAMIE PUCKETT NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 GROVE RD FL 5
GREENVILLE SC
29605-4210
US

IV. Provider business mailing address

300 E MCBEE AVE STE 300
GREENVILLE SC
29601-2899
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-4411
  • Fax: 864-455-4480
Mailing address:
  • Phone: 864-522-8611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number22946
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2019027359
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number22946
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: