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General NPI Number Information
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NPI Number | 1265113054
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Entity Type | Individual
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Provider Name | PORTIA GOODE JACKSON
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Gender | Female
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Dates
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Enumeration Date | 07/26/2023
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Last Update Date | 07/26/2023
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Provider Practice Location Address
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Address Line | 887 PINE LOG FORD RD
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City | TRAVELERS REST
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State | SC
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Zip | 29690-8418
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Country | US
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Telephone | 803-467-8687
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Fax |
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Provider Business Mailing Address
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Address Line | 887 PINE LOG FORD RD
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City | TRAVELERS REST
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State | SC
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Zip | 29690-8418
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Country | US
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Telephone | 803-467-8687
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 342000000X
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Taxonomy Name | Transportation Network Company
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License Number | 01328980
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License Number State | SC
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