Provider Demographics
NPI:1487294179
Name:STEVENS, JIMMY GREGORY
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:GREGORY
Last Name:STEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 DOUG WHITE DR STE 130
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4180
Mailing Address - Country:US
Mailing Address - Phone:843-848-1440
Mailing Address - Fax:843-839-1654
Practice Address - Street 1:920 DOUG WHITE DR STE 130
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4180
Practice Address - Country:US
Practice Address - Phone:843-848-1440
Practice Address - Fax:843-839-1654
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
SC3455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant