Provider Demographics
NPI:1710128608
Name:SCHOTTLEUTNER, JENNIFER L (PA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:SCHOTTLEUTNER
Suffix:
Gender:F
Credentials:PA
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 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4123
Practice Address - Street 1:853 N CHURCH ST
Practice Address - Street 2:SUITE 410A
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6928
Practice Address - Fax:864-560-4413
Is Sole Proprietor?:No
Enumeration Date:2009-03-23
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
SC1408363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0794PAMedicaid
SCP00761341OtherRAILROAD MEDICARE
SCP00761341OtherRAILROAD MEDICARE