Healthcare Provider Details

I. General information

NPI: 1255324190
Provider Name (Legal Business Name): LISA D JENNINGS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219A N MINE ST
MC CORMICK SC
29835-8363
US

IV. Provider business mailing address

313 MAIN ST SUITE B
GREENWOOD SC
29646-2757
US

V. Phone/Fax

Practice location:
  • Phone: 864-852-3336
  • Fax: 864-852-3339
Mailing address:
  • Phone: 864-388-0301
  • Fax: 864-388-0648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number053559
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: