Provider Demographics
NPI:1235304023
Name:HAYNES, JENNIFER B (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:B
Last Name:HAYNES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-0547
Mailing Address - Country:US
Mailing Address - Phone:843-663-8000
Mailing Address - Fax:
Practice Address - Street 1:3236 HOLMESTOWN RD
Practice Address - Street 2:SUITE E1
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7495
Practice Address - Country:US
Practice Address - Phone:843-663-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN122940363LF0000X
SC4031363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4031OtherSC STATE LICENSE
GARN122940OtherSTATE LICENSE
NC7004853Medicaid
SCNP0413Medicaid
SCNP0413Medicaid