Healthcare Provider Details

I. General information

NPI: 1700535861
Provider Name (Legal Business Name): MATTHEW RICHARD JACKSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E HOSPITAL ST
MANNING SC
29102-3149
US

IV. Provider business mailing address

607 BEAMAN ST
CLINTON NC
28328-2603
US

V. Phone/Fax

Practice location:
  • Phone: 803-435-8828
  • Fax:
Mailing address:
  • Phone: 910-592-8511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL87625
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2025-01455
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: