Provider Demographics
NPI:1982100285
Name:GOETHIE, JESSIE PERNELL (NP-C)
Entity Type:Individual
Prefix:
First Name:JESSIE
Middle Name:PERNELL
Last Name:GOETHIE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 OKATIE HWY
Mailing Address - Street 2:
Mailing Address - City:OKATIE
Mailing Address - State:SC
Mailing Address - Zip Code:29909-3963
Mailing Address - Country:US
Mailing Address - Phone:843-987-7400
Mailing Address - Fax:
Practice Address - Street 1:2210 MOSSY OAKS RD
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-1046
Practice Address - Country:US
Practice Address - Phone:843-322-1818
Practice Address - Fax:843-470-0203
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21756363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner