Healthcare Provider Details

I. General information

NPI: 1700388626
Provider Name (Legal Business Name): REBECCA E JACKSON NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 07/17/2024
Certification Date: 07/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2728 SUNSET BLVD STE 400
WEST COLUMBIA SC
29169-4872
US

IV. Provider business mailing address

PO BOX 6069
WEST COLUMBIA SC
29171-6069
US

V. Phone/Fax

Practice location:
  • Phone: 803-936-7095
  • Fax: 803-936-7908
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number21730
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: