Healthcare Provider Details

I. General information

NPI: 1497913222
Provider Name (Legal Business Name): JTA CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 W ASHFORD CT
IRMO SC
29063-8328
US

IV. Provider business mailing address

3 WEST ASHFORD CT
IRMO SC
29063
US

V. Phone/Fax

Practice location:
  • Phone: 803-781-7506
  • Fax: 803-781-7506
Mailing address:
  • Phone:
  • Fax: 803-781-7506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1640
License Number StateSC

VIII. Authorized Official

Name: JENNIFER TAYLOR ALLEN
Title or Position: LISW-CP-SUPERVISOR
Credential: MSW
Phone: 803-727-4224