Provider Demographics
NPI:1780298190
Name:BANDY, JENNIFER (PSS)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BANDY
Suffix:
Gender:F
Credentials:PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4108 LB PROPST DR
Mailing Address - Street 2:
Mailing Address - City:CONOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28613-8830
Mailing Address - Country:US
Mailing Address - Phone:828-302-3431
Mailing Address - Fax:
Practice Address - Street 1:4108 LB PROPST DR
Practice Address - Street 2:
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-8830
Practice Address - Country:US
Practice Address - Phone:828-302-3431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00584530Medicaid