Provider Demographics
NPI:1477688356
Name:CONDER, JACQUELINE IMOGENE (ACNP CS CCRN)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:IMOGENE
Last Name:CONDER
Suffix:
Gender:F
Credentials:ACNP CS CCRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2046
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171
Mailing Address - Country:US
Mailing Address - Phone:803-461-3000
Mailing Address - Fax:803-461-4914
Practice Address - Street 1:166 STONERIDGE DRIVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210
Practice Address - Country:US
Practice Address - Phone:803-461-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC959363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S21406Medicare UPIN