Provider Demographics
NPI:1093521676
Name:HALFORD, JESSICA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:HALFORD
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6000
Mailing Address - Country:US
Mailing Address - Phone:508-221-3624
Mailing Address - Fax:
Practice Address - Street 1:931 MEDICAL CIR STE A
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4122
Practice Address - Country:US
Practice Address - Phone:843-945-8117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
SC5774363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program