Healthcare Provider Details

I. General information

NPI: 1942547138
Provider Name (Legal Business Name): JENNIFER LOADHOLT MOORE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 01/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 NORTH RAILROAD AVENUE
RIDGELAND SC
29936
US

IV. Provider business mailing address

PO BOX 1343
RIDGELAND SC
29936-2623
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number10158
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: