Provider Demographics
NPI:1982944583
Name:SANDERS, JENNIFER ELLEN (CACI)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ELLEN
Last Name:SANDERS
Suffix:
Gender:F
Credentials:CACI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1547 PARKWAY
Mailing Address - Street 2:GREENWOOD
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-4081
Mailing Address - Country:US
Mailing Address - Phone:864-229-7120
Mailing Address - Fax:864-223-5526
Practice Address - Street 1:1547 PARKWAY
Practice Address - Street 2:GREENWOOD
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4081
Practice Address - Country:US
Practice Address - Phone:864-229-7120
Practice Address - Fax:864-223-5526
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10492101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC421504Medicaid
SC421504Medicaid