Provider Demographics
NPI:1194010769
Name:WOOD, JANEEN JENSEN (NP-C)
Entity Type:Individual
Prefix:
First Name:JANEEN
Middle Name:JENSEN
Last Name:WOOD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 RIVER CREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063
Mailing Address - Country:US
Mailing Address - Phone:803-318-8346
Mailing Address - Fax:803-400-3569
Practice Address - Street 1:1008 LAKE MURRAY BLVD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2821
Practice Address - Country:US
Practice Address - Phone:803-749-3840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-12
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF0511082363LF0000X
SC17985363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D0978186Medicare UPIN