Healthcare Provider Details

I. General information

NPI: 1780154740
Provider Name (Legal Business Name): JACQUELYN M PRUITT NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 06/30/2021
Certification Date: 06/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

772 N TOWNVILLE ST
SENECA SC
29678-2645
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-886-9300
  • Fax: 864-886-9399
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22107
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: