Healthcare Provider Details

I. General information

NPI: 1538140025
Provider Name (Legal Business Name): MISTI JACKSON BURGESS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISTI ALISHA JACKSON FNP

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 06/29/2020
Certification Date: 06/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 DELAWARE ST
GREENVILLE SC
29605-5495
US

IV. Provider business mailing address

749 E VICTOR HILL RD
DUNCAN SC
29334-9230
US

V. Phone/Fax

Practice location:
  • Phone: 864-591-1839
  • Fax: 864-582-5023
Mailing address:
  • Phone: 864-591-0992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN 2665
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: