Provider Demographics
NPI:1982647525
Name:WALDRON, JACQUELYN B (NP)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:B
Last Name:WALDRON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22580 HIGHWAY 76 E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360-8439
Mailing Address - Country:US
Mailing Address - Phone:864-833-5986
Mailing Address - Fax:864-833-0599
Practice Address - Street 1:22580 HIGHWAY 76 E
Practice Address - Street 2:SUITE 100
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-8439
Practice Address - Country:US
Practice Address - Phone:864-833-5986
Practice Address - Fax:864-833-0599
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR40094363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0249Medicaid