Provider Demographics
NPI:1033970462
Name:LIGHT, JADEN BREYANNE (NP)
Entity Type:Individual
Prefix:
First Name:JADEN
Middle Name:BREYANNE
Last Name:LIGHT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2017 ASTON MILL PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-4072
Mailing Address - Country:US
Mailing Address - Phone:330-546-5819
Mailing Address - Fax:
Practice Address - Street 1:1935 HOLBROOK RD STE 2200
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-9675
Practice Address - Country:US
Practice Address - Phone:803-650-4281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC28301208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics