Provider Demographics
NPI:1033590575
Name:PSALTIS, JENNIFER DAWN (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:DAWN
Last Name:PSALTIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:DAWN
Other - Last Name:MABRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:151 PEACHWOOD CENTRE DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2575
Practice Address - Country:US
Practice Address - Phone:864-560-9627
Practice Address - Fax:864-562-5470
Is Sole Proprietor?:No
Enumeration Date:2015-06-10
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19465363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC61005019OtherMEDICARE PIN
SCSC6100J577OtherMEDICARE PIN
SCSC61006067OtherMEDICARE PIN
SCSC61006121OtherMEDICARE PIN
SCNP3262Medicaid