1780154740 NPI number — MRS. JACQUELYN M PRUITT NP-C

Table of content: MRS. JACQUELYN M PRUITT NP-C (NPI 1780154740)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780154740 NPI number — MRS. JACQUELYN M PRUITT NP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRUITT
Provider First Name:
JACQUELYN
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780154740
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 E MCBEE AVE FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29601-2842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-522-8603
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
772 N TOWNVILLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SENECA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29678-2645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-886-9300
Provider Business Practice Location Address Fax Number:
864-886-9399
Provider Enumeration Date:
12/03/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  22107 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NP5689 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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