Healthcare Provider Details

I. General information

NPI: 1255385738
Provider Name (Legal Business Name): JACQUELINE DAVIS HAITHCOCK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

776 DANIEL ELLIS DR
CHARLESTON SC
29412-3094
US

IV. Provider business mailing address

776 DANIEL ELLIS DR
CHARLESTON SC
29412-3094
US

V. Phone/Fax

Practice location:
  • Phone: 843-795-8100
  • Fax: 843-762-3010
Mailing address:
  • Phone: 843-795-8100
  • Fax: 843-762-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number16814
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: