Provider Demographics
NPI:1245829928
Name:RILEY, JACQUETTA
Entity type:Individual
Prefix:
First Name:JACQUETTA
Middle Name:
Last Name:RILEY
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 1:1550 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-4944
Mailing Address - Country:US
Mailing Address - Phone:803-533-5489
Mailing Address - Fax:
Practice Address - Street 1:1550 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4944
Practice Address - Country:US
Practice Address - Phone:803-533-5489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP47848164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherVACCINES
SC0511SCOtherVACCINATING
000Other0000