Basic Information
| Provider Information | |||||||||
| NPI: | 1538182324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | BAILEY | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751649 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437891620 | ||||||||
| FaxNumber: | 8437242440 | ||||||||
| Practice Location | |||||||||
| Address1: | 4278 LADSON RD | ||||||||
| Address2: | |||||||||
| City: | LADSON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294565452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432032240 | ||||||||
| FaxNumber: | 8432032241 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1022 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00784094 | 01 | SC | RAILROAD MEDICARE-EFF 5/1/2009 | OTHER | P00638306 | 01 | SC | RAILROAD MEDICARE | OTHER | 010222 | 05 | SC | MEDICAID |