Basic Information
| Provider Information | |||||||||
| NPI: | 1891937926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EBERT | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 DOCTOR CIR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004910909 | ||||||||
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| Practice Location | |||||||||
| Address1: | 111 DOCTOR CIR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292036502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004910909 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2009 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3857 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3857 | 01 | SC | SC LICENSE | OTHER | NP1494 | 05 | SC | MEDICAID |