Provider Demographics
NPI:1336171487
Name:JEANJAQUET, MARK S (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:JEANJAQUET
Suffix:
Gender:M
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:PO BOX 829
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-0829
Mailing Address - Country:US
Mailing Address - Phone:843-347-8015
Mailing Address - Fax:843-347-8017
Practice Address - Street 1:300 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9142
Practice Address - Country:US
Practice Address - Phone:843-347-8015
Practice Address - Fax:843-347-8017
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18065207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
930045476OtherMEDICARE RAILROAD
SC180654Medicaid
20017271OtherFIRST CHOICE
930045476OtherMEDICARE RAILROAD
SCG141508822Medicare PIN