=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992511216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JADE HAZEL PACK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2024
-----------------------------------------------------
Last Update Date | 04/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 SUNSET DR
-----------------------------------------------------
City | MANNING
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29102-2904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-435-4447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1615 ZOAR CHURCH RD
-----------------------------------------------------
City | SUMTER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29153-9180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-464-8697
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 29972
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 263902
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------