Healthcare Provider Details

I. General information

NPI: 1801066584
Provider Name (Legal Business Name): JESSICA I. OLIVER LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 STONEY LANDING ROAD
MONCKS CORNER SC
29461-3967
US

IV. Provider business mailing address

PO BOX 1030
MONCKS CORNER SC
29461-3967
US

V. Phone/Fax

Practice location:
  • Phone: 843-761-8282
  • Fax: 843-761-7308
Mailing address:
  • Phone: 843-761-8282
  • Fax: 843-761-7308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10184
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number004345
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number072659-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: