Healthcare Provider Details

I. General information

NPI: 1366627002
Provider Name (Legal Business Name): MRS. JACQUELYN MARIE JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 12/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 HIWAY 41
MT PLEASANT SC
29464
US

IV. Provider business mailing address

PO BOX 2522
MT PLEASANT SC
29464
US

V. Phone/Fax

Practice location:
  • Phone: 843-870-1839
  • Fax:
Mailing address:
  • Phone: 843-870-1839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number120514E
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number120514E
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: