MEDICARE: JENNIFER DAWN WADDELL HIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	237700000X	Hearing Instrument Specialist	HAS-0524	SC

General Provider Information

NPI Number	:	1275903676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER DAWN WADDELL HIS

Provider Business Mailing Address
First Line	:	PO BOX 80623
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29680-0011
Country	:	US
Telephone Number	:	864-881-1663
Fax Number	:	864-751-7524

Provider Business Practice Location Address
First Line	:	857 NE MAIN ST
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-2041
Country	:	US
Telephone Number	:	864-881-1663
Fax Number	:	864-751-7524

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2015
Last Update Date	:	09/29/2015

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