Healthcare Provider Details

I. General information

NPI: 1558318527
Provider Name (Legal Business Name): KIMBERLY SHELLEY JACKSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

864 ISLAND PARK DR STE 101
DANIEL ISLAND SC
29492-7446
US

IV. Provider business mailing address

PO BOX 602108
CHARLOTTE NC
28260-2108
US

V. Phone/Fax

Practice location:
  • Phone: 843-876-7975
  • Fax:
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number18009
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: