Provider Demographics
NPI:1265984678
Name:CROCKER, JODI CAMERON (NP)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:CAMERON
Last Name:CROCKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JODI
Other - Middle Name:CAMERON
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:840 W FLOYD BAKER BLVD
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-1845
Practice Address - Country:US
Practice Address - Phone:864-489-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC232011163WS0200X
SC23001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCF6436067OtherMEDICARE PIN
SCSCF6436121OtherMEDICARE PIN
SCSCF643J577OtherMEDICARE PIN
SCNP6022Medicaid
SCSCF6435019OtherMEDICARE PIN
SCSCF6436084OtherMEDICARE PIN