Provider Demographics
NPI:1407197312
Name:AMICK, JACQUELYNN MARIE
Entity type:Individual
Prefix:
First Name:JACQUELYNN
Middle Name:MARIE
Last Name:AMICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 EXECUTIVE CENTER DR
Mailing Address - Street 2:STE. 120
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-8411
Mailing Address - Country:US
Mailing Address - Phone:843-855-0597
Mailing Address - Fax:803-896-8279
Practice Address - Street 1:101 EXECUTIVE CENTER DR
Practice Address - Street 2:STE. 120
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-8411
Practice Address - Country:US
Practice Address - Phone:843-855-0597
Practice Address - Fax:803-896-8279
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency