Provider Demographics
NPI:1750534509
Name:CICCHILLO, JENNIFER L (NPC)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:L
Last Name:CICCHILLO
Suffix:
Gender:F
Credentials:NPC
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 100523
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-0523
Mailing Address - Country:US
Mailing Address - Phone:843-669-5162
Mailing Address - Fax:843-667-4573
Practice Address - Street 1:327 AIKEN HUNT CIR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-8407
Practice Address - Country:US
Practice Address - Phone:843-669-5162
Practice Address - Fax:843-667-4573
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2025-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08356363LA2200X
OHRX08356363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health