Provider Demographics
NPI:1760873384
Name:DRAKE, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DRAKE
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 1:385 SPEARS CREEK CHURCH RD STE B
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-8446
Mailing Address - Country:US
Mailing Address - Phone:803-929-7408
Mailing Address - Fax:888-711-0441
Practice Address - Street 1:385 SPEARS CREEK CHURCH RD STE B
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-8446
Practice Address - Country:US
Practice Address - Phone:803-929-7408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8418225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8418OtherPHYSICAL THERAPY LICENSES