Healthcare Provider Details

I. General information

NPI: 1831031087
Provider Name (Legal Business Name): JACKSON SALINE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7921 BROAD RIVER RD
IRMO SC
29063-2358
US

IV. Provider business mailing address

7921 BROAD RIVER RD
IRMO SC
29063-2358
US

V. Phone/Fax

Practice location:
  • Phone: 803-749-7494
  • Fax:
Mailing address:
  • Phone: 803-749-7494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2301401713
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5359
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: