MEDICARE: DR. JOSEPH P JACKSON JR. M.D.

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	174400000X	Specialist	7447	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	010026253	OTHER	SC	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790781177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOSEPH P JACKSON JR. M.D.

Provider Business Mailing Address
First Line	:	507 WALNUT ST
Second Line	:
City	:	CAMDEN
State	:	SC
Zip	:	29020-3649
Country	:	US
Telephone Number	:	803-432-9300
Fax Number	:	803-432-9307

Provider Business Practice Location Address
First Line	:	507 WALNUT ST
Second Line	:
City	:	CAMDEN
State	:	SC
Zip	:	29020-3649
Country	:	US
Telephone Number	:	803-432-9300
Fax Number	:	803-432-9307

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	05/21/2008

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