Healthcare Provider Details

I. General information

NPI: 1588108112
Provider Name (Legal Business Name): JESSICA TAYLOR GLYMPH FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2016
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12016 N RADIO STATION RD
SENECA SC
29678-1143
US

IV. Provider business mailing address

1 INDEPENDENCE PT SUITE 212
GREENVILLE SC
29615-4545
US

V. Phone/Fax

Practice location:
  • Phone: 864-882-6141
  • Fax: 864-882-6680
Mailing address:
  • Phone: 896-797-6306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number20651
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: