Healthcare Provider Details

I. General information

NPI: 1740866458
Provider Name (Legal Business Name): JALISSA NEWTON LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 HAZZARD CREEK VLG STE C
RIDGELAND SC
29936-8266
US

IV. Provider business mailing address

PO BOX 205
ESTILL SC
29918-0205
US

V. Phone/Fax

Practice location:
  • Phone: 843-645-7700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number7247
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: