MEDICARE: MR. LARRY RANDOLPH JACKSON REGISTERED NURSE

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	163WP0808X	Psychiatric/Mental Health Registered Nurse	56879	SC

General Provider Information

NPI Number	:	1093878191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LARRY RANDOLPH JACKSON REGISTERED NURSE

Provider Business Mailing Address
First Line	:	615 RAPIDS RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-3024
Country	:	US
Telephone Number	:	803-798-2211
Fax Number	:

Provider Business Practice Location Address
First Line	:	615 RAPIDS RD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-3024
Country	:	US
Telephone Number	:	803-798-2211
Fax Number	:

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

Provider Enumeration Date	:	12/19/2006
Last Update Date	:	07/08/2007

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