Healthcare Provider Details

I. General information

NPI: 1952789638
Provider Name (Legal Business Name): BROOKE JACKSON GERLACH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BROOKE ELISABETH JACKSON

II. Dates (important events)

Enumeration Date: 05/13/2015
Last Update Date: 08/19/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 REMANT RD
HANAHAN SC
29410
US

IV. Provider business mailing address

1038 SALTWATER CIRCLE
JOHNS ISLAND SC
29455
US

V. Phone/Fax

Practice location:
  • Phone: 843-410-5608
  • Fax:
Mailing address:
  • Phone: 864-790-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLRD.1256
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3074
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: