Healthcare Provider Details

I. General information

NPI: 1366860850
Provider Name (Legal Business Name): JENNIFER REYNOLDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 04/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 BRIDGE VIEW DR STE 600
N CHARLESTON SC
29405-8415
US

IV. Provider business mailing address

4050 BRIDGE VIEW DR STE 600
N CHARLESTON SC
29405-8415
US

V. Phone/Fax

Practice location:
  • Phone: 843-953-0307
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number326
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number204285
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: