Healthcare Provider Details

I. General information

NPI: 1801748736
Provider Name (Legal Business Name): JESSICA MCCORKLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2026
Last Update Date: 02/12/2026
Certification Date: 02/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 STONECREST BLVD
TEGA CAY SC
29708-6555
US

IV. Provider business mailing address

1151 STONECREST BLVD
TEGA CAY SC
29708-6555
US

V. Phone/Fax

Practice location:
  • Phone: 803-578-4135
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number1496
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: