Healthcare Provider Details

I. General information

NPI: 1215400080
Provider Name (Legal Business Name): MRS. BRIDGET JAKIA FORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 E WOOD ST
SPARTANBURG SC
29303-3016
US

IV. Provider business mailing address

1600 BETHPAGE DR APT 23
SPARTANBURG SC
29301-3342
US

V. Phone/Fax

Practice location:
  • Phone: 864-596-2227
  • Fax:
Mailing address:
  • Phone: 803-236-2068
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number235423
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: