Basic Information
Provider Information | |||||||||
NPI: | 1891079018 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CRAIG | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RD, CSR, LD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 118008 | ||||||||
Address2: |   | ||||||||
City: | N CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294238008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8435727727 | ||||||||
FaxNumber: | 8435695881 | ||||||||
Practice Location | |||||||||
Address1: | 2500 ELMS CENTER RD | ||||||||
Address2: |   | ||||||||
City: | N CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294069844 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8435727727 | ||||||||
FaxNumber: | 8435695881 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/06/2011 | ||||||||
LastUpdateDate: | 09/21/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | 951 | SC | N |   | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 133V00000X | 951 | SC | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
ID Information
ID | Type | State | Issuer | Description | DT1038 | 05 | SC |   | MEDICAID |