Healthcare Provider Details

I. General information

NPI: 1821911868
Provider Name (Legal Business Name): JESSICA L SHANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 COMMERCE ST
MANNING SC
29102-2638
US

IV. Provider business mailing address

1230 S PIKE E LOT 78
SUMTER SC
29153-5174
US

V. Phone/Fax

Practice location:
  • Phone: 803-435-2124
  • Fax:
Mailing address:
  • Phone: 803-566-1513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number103770435
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: