Provider Demographics
NPI:1942271622
Name:JENNINGS, ROBERTA (NP)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:NP
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:864-560-4413
Practice Address - Street 1:853 N CHURCH ST
Practice Address - Street 2:SUITE 510
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3098
Practice Address - Country:US
Practice Address - Phone:864-560-6193
Practice Address - Fax:864-560-1510
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2321363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0240Medicaid
SC196540OtherMEDCOST
SCCN1627OtherRR MEDICARE
SCQ31833Medicare PIN
SCNP0240Medicaid
SC080072334Medicare PIN
SCAA40623365Medicare PIN