Healthcare Provider Details

I. General information

NPI: 1629311535
Provider Name (Legal Business Name): JESSICA RENEE PETTIT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3226 MAYBANK HWY STE C
JOHNS ISLAND SC
29455-4860
US

IV. Provider business mailing address

3226 MAYBANK HWY STE C
JOHNS ISLAND SC
29455-4860
US

V. Phone/Fax

Practice location:
  • Phone: 843-266-9800
  • Fax:
Mailing address:
  • Phone: 843-266-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6017
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: