Provider Demographics
NPI:1700131802
Name:NEWSOM, JENNIFER MELISSA (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MELISSA
Last Name:NEWSOM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MISSY
Other - Middle Name:
Other - Last Name:NEWSOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:532 COUNTRY PLACE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8258
Mailing Address - Country:US
Mailing Address - Phone:501-339-7400
Mailing Address - Fax:
Practice Address - Street 1:120C SPRINGHALL DR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5335
Practice Address - Country:US
Practice Address - Phone:843-216-0290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPT 66732251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T910OtherBLUE CROSS BLUE SHIELD