Provider Demographics
NPI:1124563648
Name:ALTMAN, JESSICA BENTON
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BENTON
Last Name:ALTMAN
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 1:1025 RIVERLAND WOODS PL
Mailing Address - Street 2:#408
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4133
Mailing Address - Country:US
Mailing Address - Phone:843-908-3120
Mailing Address - Fax:
Practice Address - Street 1:219 S LEMACKS ST
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-4374
Practice Address - Country:US
Practice Address - Phone:843-549-1516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20448363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health