Provider Demographics
NPI:1952044695
Name:DRERUP, JENNIFER LEE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:DRERUP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 ASHLEY AVE RM 202
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8905
Mailing Address - Country:US
Mailing Address - Phone:843-792-4538
Mailing Address - Fax:
Practice Address - Street 1:135 RUTLEDGE AVE FL 5
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8903
Practice Address - Country:US
Practice Address - Phone:843-792-4538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SCLL88281208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program