Provider Demographics
NPI:1366836371
Name:EDWARDS, JACQUELYN EVANS (MSP, SLP-CCC)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:EVANS
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:MSP, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 W CLARKE RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-0722
Mailing Address - Country:US
Mailing Address - Phone:843-669-4374
Mailing Address - Fax:
Practice Address - Street 1:133 W CLARKE RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-0722
Practice Address - Country:US
Practice Address - Phone:843-669-4374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3952235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist