Provider Demographics
NPI:1952387979
Name:BEATTY, JENNIFER F (DO)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:F
Last Name:BEATTY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4975 LACROSS RD STE 110
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-6531
Mailing Address - Country:US
Mailing Address - Phone:843-797-1941
Mailing Address - Fax:843-574-1698
Practice Address - Street 1:4975 LACROSS RD STE 110
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-797-1941
Practice Address - Fax:843-574-1698
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC910208600000X
SC212870208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC009109Medicaid
SC009109Medicaid