Provider Demographics
NPI:1699765768
Name:JAHNKE, JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:JAHNKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-9630
Mailing Address - Country:US
Mailing Address - Phone:803-758-2602
Mailing Address - Fax:803-253-8896
Practice Address - Street 1:2475 BROAD ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1820
Practice Address - Country:US
Practice Address - Phone:803-778-6555
Practice Address - Fax:803-773-8226
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1066142363A00000X
SC2470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC570769093Medicaid