Provider Demographics
NPI:1255543799
Name:SKINNER, JACQULYN M (LISW-CP)
Entity type:Individual
Prefix:
First Name:JACQULYN
Middle Name:M
Last Name:SKINNER
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:SKINNER-JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4 LITTLEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-1430
Mailing Address - Country:US
Mailing Address - Phone:864-612-1500
Mailing Address - Fax:864-542-2324
Practice Address - Street 1:601 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29301-2105
Practice Address - Country:US
Practice Address - Phone:864-612-1500
Practice Address - Fax:864-542-2324
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0069941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ351330281OtherMEDICARE PTAN