Provider Demographics
NPI:1831332212
Name:ARCHER, JENNIFER
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:ARCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1732 VILLAGE PARK DR
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-2457
Mailing Address - Country:US
Mailing Address - Phone:803-534-7600
Mailing Address - Fax:803-534-7636
Practice Address - Street 1:710 RABON RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-8903
Practice Address - Country:US
Practice Address - Phone:803-419-6646
Practice Address - Fax:803-419-6626
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3213225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3213OtherSC LICENSE #3213