Provider Demographics
NPI:1508514571
Name:GARDNER, JADA ALICIA
Entity Type:Individual
Prefix:
First Name:JADA
Middle Name:ALICIA
Last Name:GARDNER
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 1:200 WILLIES RD
Mailing Address - Street 2:
Mailing Address - City:YEMASSEE
Mailing Address - State:SC
Mailing Address - Zip Code:29945-2846
Mailing Address - Country:US
Mailing Address - Phone:334-333-3504
Mailing Address - Fax:
Practice Address - Street 1:140 RAYLAND CIR
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-9400
Practice Address - Country:US
Practice Address - Phone:843-701-2633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider