Healthcare Provider Details

I. General information

NPI: 1467146522
Provider Name (Legal Business Name): JENNIFER ROBERTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 LANSFORD CT STE 202
MYRTLE BEACH SC
29588-3501
US

IV. Provider business mailing address

112 SALUDA RIDGE CT STE 200
WEST COLUMBIA SC
29169-3461
US

V. Phone/Fax

Practice location:
  • Phone: 843-638-6860
  • Fax: 803-999-1754
Mailing address:
  • Phone: 803-999-1750
  • Fax: 803-999-1754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number27225
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: