MEDICARE: BRANDY JACKSON DC

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	3479	SC

General Provider Information

NPI Number	:	1750687513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY JACKSON DC

Provider Business Mailing Address
First Line	:	PO BOX 125
Second Line	:
City	:	WAGENER
State	:	SC
Zip	:	29164-0125
Country	:	US
Telephone Number	:	803-564-6000
Fax Number	:	803-564-6011

Provider Business Practice Location Address
First Line	:	147 MAIN STREET
Second Line	:
City	:	WAGENER
State	:	SC
Zip	:	29164-9442
Country	:	US
Telephone Number	:	803-564-6000
Fax Number	:	803-564-6011

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

Provider Enumeration Date	:	01/26/2011
Last Update Date	:	08/29/2013

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Directions to “ BRANDY JACKSON DC” Practice Location

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