Healthcare Provider Details

I. General information

NPI: 1841270212
Provider Name (Legal Business Name): JACK WILSON RHYNE LCSW, LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 03/19/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 STATE RD
CHERAW SC
29520
US

IV. Provider business mailing address

PO BOX 1090
HARTSVILLE SC
29551-1090
US

V. Phone/Fax

Practice location:
  • Phone: 843-537-0961
  • Fax: 843-537-0908
Mailing address:
  • Phone: 843-857-0111
  • Fax: 843-857-0206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC002180
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number004880
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: