Healthcare Provider Details

I. General information

NPI: 1679421366
Provider Name (Legal Business Name): JACKSON SPILLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2026
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 BEE ST
CHARLESTON SC
29425-0001
US

IV. Provider business mailing address

35 IDAHO RD
BONNERS FERRY ID
83805-3300
US

V. Phone/Fax

Practice location:
  • Phone: 843-876-7645
  • Fax:
Mailing address:
  • Phone: 360-610-1777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: