Healthcare Provider Details

I. General information

NPI: 1578829982
Provider Name (Legal Business Name): KRYSTIN MONET JACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRYSTIN HARRISON MD

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

IV. Provider business mailing address

300 SINGLETON RIDGE RD
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-234-5139
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME123123
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number83059
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: