Healthcare Provider Details

I. General information

NPI: 1497199400
Provider Name (Legal Business Name): JESSICA JACKSON RUEB M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA NICOLE JACKSON JESSICA JACKSON

II. Dates (important events)

Enumeration Date: 04/20/2013
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MIDLANDS CT
WEST COLUMBIA SC
29169-3456
US

IV. Provider business mailing address

115 MIDLANDS CT
WEST COLUMBIA SC
29169-3456
US

V. Phone/Fax

Practice location:
  • Phone: 803-457-7000
  • Fax: 803-457-7001
Mailing address:
  • Phone: 803-312-4814
  • Fax: 803-457-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number35134272
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: