Healthcare Provider Details

I. General information

NPI: 1114286150
Provider Name (Legal Business Name): MRS. CHRISTINE STEVENS JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2012
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 LIBERTY ST
MC CLELLANVILLE SC
29458-9721
US

IV. Provider business mailing address

161 LIBERTY ST
MC CLELLANVILLE SC
29458-9721
US

V. Phone/Fax

Practice location:
  • Phone: 843-230-9297
  • Fax:
Mailing address:
  • Phone: 843-230-9297
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number1600
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: