Healthcare Provider Details

I. General information

NPI: 1073688602
Provider Name (Legal Business Name): JACKSON DAVENPORT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

379 KING ST
CHARLESTON SC
29401-1438
US

IV. Provider business mailing address

PO BOX 20236
CHARLESTON SC
29413-0236
US

V. Phone/Fax

Practice location:
  • Phone: 843-722-4416
  • Fax: 843-720-8984
Mailing address:
  • Phone: 843-722-4416
  • Fax: 843-720-8984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number152
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number509
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number501
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number509
License Number StateSC

VIII. Authorized Official

Name: MRS. NANCY WATKINS DAVENPORT
Title or Position: MANAGER
Credential:
Phone: 843-722-4416