Provider Demographics
NPI:1649604000
Name:HERNDON, JEFFREY WALTER
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:WALTER
Last Name:HERNDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 ACADEMY RD
Mailing Address - Street 2:
Mailing Address - City:WALTERBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29488-9266
Mailing Address - Country:US
Mailing Address - Phone:843-893-8122
Mailing Address - Fax:843-549-2650
Practice Address - Street 1:990 ACADEMY RD
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-9266
Practice Address - Country:US
Practice Address - Phone:843-893-8122
Practice Address - Fax:843-549-2650
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC165834302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization