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General NPI Number Information
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NPI Number | 1073688602
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Entity Type | Organization
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Legal Business Name | JACKSON DAVENPORT INC.
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Dates
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Enumeration Date | 11/21/2006
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Last Update Date | 07/16/2014
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Provider Practice Location Address
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Address Line | 379 KING ST
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City | CHARLESTON
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State | SC
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Zip | 29401-1438
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Country | US
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Telephone | 843-722-4416
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Fax | 843-720-8984
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Provider Business Mailing Address
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Address Line | PO BOX 20236
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City | CHARLESTON
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State | SC
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Zip | 29413-0236
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Country | US
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Telephone | 843-722-4416
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Fax | 843-720-8984
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. NANCY WATKINS DAVENPORT
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Credential |
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Telephone | 843-722-4416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FC0801X
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Taxonomy Name | Contact Lens Fitter
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License Number | 152
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | 509
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number | 501
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License Number State | SC
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Taxonomy #4
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 509
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License Number State | SC
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