Healthcare Provider Details

I. General information

NPI: 1811511199
Provider Name (Legal Business Name): SAMUEL COLLINS JACKSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 LANDAU LN
MT PLEASANT SC
29466-7300
US

IV. Provider business mailing address

5111 N RHETT AVE
NORTH CHARLESTON SC
29405-4219
US

V. Phone/Fax

Practice location:
  • Phone: 843-375-5448
  • Fax:
Mailing address:
  • Phone: 843-804-9478
  • Fax: 843-804-9020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number10222
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: