Provider Demographics
NPI:1043940331
Name:O'SHIELDS, JENNA NICHOLE (LDO,NCLE,ABOC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:NICHOLE
Last Name:O'SHIELDS
Suffix:
Gender:F
Credentials:LDO,NCLE,ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14055 E WADE HAMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29651-1500
Mailing Address - Country:US
Mailing Address - Phone:864-877-5248
Mailing Address - Fax:864-877-3174
Practice Address - Street 1:14055 E WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29651-1500
Practice Address - Country:US
Practice Address - Phone:864-877-5248
Practice Address - Fax:864-877-3174
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1102156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician