Provider Demographics
NPI:1730698580
Name:PITTARD, JENNIFER MOON (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MOON
Last Name:PITTARD
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-785-4777
Mailing Address - Fax:803-358-6240
Practice Address - Street 1:811 W MAIN ST STE 201&209
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2507
Practice Address - Country:US
Practice Address - Phone:803-785-4777
Practice Address - Fax:803-358-6240
Is Sole Proprietor?:No
Enumeration Date:2017-09-25
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21335363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4799Medicaid