Healthcare Provider Details

I. General information

NPI: 1124538285
Provider Name (Legal Business Name): JACQUELINE LAXTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2017
Last Update Date: 10/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 SHERIDAN PARK CIR STE C
BLUFFTON SC
29910-7023
US

IV. Provider business mailing address

27 OUTPOST LN
HILTON HEAD ISLAND SC
29928-3821
US

V. Phone/Fax

Practice location:
  • Phone: 843-815-5628
  • Fax:
Mailing address:
  • Phone: 843-816-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number3795
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: