Healthcare Provider Details

I. General information

NPI: 1790449882
Provider Name (Legal Business Name): KEELAN RAPHAEL JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 BOULEVARD DE FRANCE
PARRIS ISLAND SC
29905
US

IV. Provider business mailing address

670 BOULEVARD DE FRANCE
PARRIS ISLAND SC
29905
US

V. Phone/Fax

Practice location:
  • Phone: 843-228-4757
  • Fax:
Mailing address:
  • Phone: 843-228-4757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number1790449882
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: