Healthcare Provider Details

I. General information

NPI: 1548924079
Provider Name (Legal Business Name): JENNIFER RAE STOGSDILL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2021
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 BRIGHTON PARK BLVD
SUMMERVILLE SC
29486-3100
US

IV. Provider business mailing address

424 BRIGHTON PARK BLVD
SUMMERVILLE SC
29486-3100
US

V. Phone/Fax

Practice location:
  • Phone: 843-376-6151
  • Fax:
Mailing address:
  • Phone: 843-376-6151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4186
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4186
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: