Provider Demographics
NPI:1306202718
Name:VANDERLIP, JADA (MS, ATC)
Entity Type:Individual
Prefix:MRS
First Name:JADA
Middle Name:
Last Name:VANDERLIP
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 SANDY KNOWE LN
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-6934
Mailing Address - Country:US
Mailing Address - Phone:843-458-5392
Mailing Address - Fax:
Practice Address - Street 1:115 SANDY KNOWE LN
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-6934
Practice Address - Country:US
Practice Address - Phone:843-458-5392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer