Provider Demographics
NPI:1164001517
Name:GOSSETT, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:GOSSETT
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 1:688 LANDS END RD
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29920-6601
Mailing Address - Country:US
Mailing Address - Phone:843-991-9892
Mailing Address - Fax:
Practice Address - Street 1:595 W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:VARNVILLE
Practice Address - State:SC
Practice Address - Zip Code:29944-4735
Practice Address - Country:US
Practice Address - Phone:843-991-9892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24826363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily