Healthcare Provider Details

I. General information

NPI: 1023831104
Provider Name (Legal Business Name): STACEY A JACKSON REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/08/2024
Certification Date: 11/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MCLEOD HEALTH BLVD STE 101
MYRTLE BEACH SC
29579-4477
US

IV. Provider business mailing address

555 E CHEVES ST
FLORENCE SC
29506-2617
US

V. Phone/Fax

Practice location:
  • Phone: 843-646-8200
  • Fax:
Mailing address:
  • Phone: 843-777-2000
  • Fax: 843-777-5465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number258919
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number258919
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: