Provider Demographics
NPI:1962833798
Name:FORREST, JEANETTE
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:FORREST
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:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:8 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 400
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8005
Practice Address - Country:US
Practice Address - Phone:803-765-0871
Practice Address - Fax:803-765-9215
Is Sole Proprietor?:No
Enumeration Date:2013-12-04
Last Update Date:2019-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18545363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2640Medicaid
SCSC24989988Medicare PIN
SCNP2640Medicaid