=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134495906
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSICA EPPS WILKES DNP, APRN, FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2012
-----------------------------------------------------
Last Update Date | 03/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 E DEKALB ST # C
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29020-4432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-713-0806
-----------------------------------------------------
Fax | 803-713-0526
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 E DEKALB ST # C
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29020-4432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-713-0806
-----------------------------------------------------
Fax | 803-713-0526
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F4408
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------