Provider Demographics
NPI:1285170589
Name:DAVIS, JANE (RN)
Entity type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10048 TEPA PL
Mailing Address - Street 2:
Mailing Address - City:TEGA CAY
Mailing Address - State:SC
Mailing Address - Zip Code:29708-9330
Mailing Address - Country:US
Mailing Address - Phone:803-287-7649
Mailing Address - Fax:
Practice Address - Street 1:448 LAKESHORE PKWY
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4264
Practice Address - Country:US
Practice Address - Phone:803-329-3177
Practice Address - Fax:803-329-3319
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC102585261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1568476885Medicaid
SC1568476885Medicaid