Healthcare Provider Details

I. General information

NPI: 1902866965
Provider Name (Legal Business Name): ALLEN B JACKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8761 DORCHESTER RD STE 100
NORTH CHARLESTON SC
29420-7320
US

IV. Provider business mailing address

PO BOX 13955
CHARLESTON SC
29422-3955
US

V. Phone/Fax

Practice location:
  • Phone: 843-767-3323
  • Fax: 843-767-4252
Mailing address:
  • Phone: 843-764-0770
  • Fax: 843-863-0402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number13680
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13680
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: