Healthcare Provider Details

I. General information

NPI: 1669310090
Provider Name (Legal Business Name): MITCHELL WELLS JACOCKS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 SUNSET CT STE 200
WEST COLUMBIA SC
29169-2464
US

IV. Provider business mailing address

145 SUNSET CT STE 200
WEST COLUMBIA SC
29169-2464
US

V. Phone/Fax

Practice location:
  • Phone: 803-314-9360
  • Fax: 803-314-9361
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: