Provider Demographics
NPI:1033653910
Name:BIANCA JARDIN PHD LLC
Entity type:Organization
Organization Name:BIANCA JARDIN PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:BIANCA
Authorized Official - Middle Name:
Authorized Official - Last Name:JARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:812-401-0941
Mailing Address - Street 1:1050 JOHNNIE DODDS BLVD, # 2381
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29465-2381
Mailing Address - Country:US
Mailing Address - Phone:812-401-0941
Mailing Address - Fax:843-480-9579
Practice Address - Street 1:1050 JOHNNIE DODDS BLVD, #2381
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29465-2801
Practice Address - Country:US
Practice Address - Phone:812-401-0941
Practice Address - Fax:843-480-9579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-12
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1285103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPG0176Medicaid