Provider Demographics
NPI:1366407249
Name:JAMESON, THERESA (CRNA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:JAMESON
Suffix:
Gender:F
Credentials:CRNA
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 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-765-1838
Mailing Address - Fax:803-765-1732
Practice Address - Street 1:3000 ST. MATTHEWS ROAD
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118
Practice Address - Country:US
Practice Address - Phone:803-454-2613
Practice Address - Fax:803-765-1732
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC403367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576008010006OtherBLUE CHOICE
SC000000163661OtherUNISON
SC20010745OtherFIRST CHOICE
SC576008010015OtherTRICARE
SCAN0273Medicaid
SC576008010009OtherBCBS
SC576008010009OtherBCBS
SC000000163661OtherUNISON