MEDICARE: DR. ANGENIQUE GLORIANN JACKSON D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	4320	SC

General Provider Information

NPI Number	:	1023513363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANGENIQUE GLORIANN JACKSON D.C.

Provider Business Mailing Address
First Line	:	316 INLAND COVE CT
Second Line	:
City	:	CLOVER
State	:	SC
Zip	:	29710-8071
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1171 MARKET ST STE 112
Second Line	:
City	:	FORT MILL
State	:	SC
Zip	:	29708-6502
Country	:	US
Telephone Number	:	803-802-7799
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2018
Last Update Date	:	03/28/2018

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