Provider Demographics
NPI:1548924079
Name:STOGSDILL, JENNIFER RAE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAE
Last Name:STOGSDILL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 BRIGHTON PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-3100
Mailing Address - Country:US
Mailing Address - Phone:843-376-6151
Mailing Address - Fax:
Practice Address - Street 1:424 BRIGHTON PARK BLVD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-3100
Practice Address - Country:US
Practice Address - Phone:843-376-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-30
Last Update Date:2025-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4186363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5009PAMedicaid