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General NPI Number Information
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NPI Number | 1366627002
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Entity Type | Individual
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Provider Name | MRS. JACQUELYN MARIE JACKSON
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Gender | Female
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Dates
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Enumeration Date | 12/31/2007
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Last Update Date | 12/31/2007
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Provider Practice Location Address
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Address Line | 1609 HIWAY 41
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City | MT PLEASANT
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State | SC
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Zip | 29464
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Country | US
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Telephone | 843-870-1839
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2522
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City | MT PLEASANT
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State | SC
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Zip | 29464
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Country | US
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Telephone | 843-870-1839
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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 | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number | 120514E
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License Number State |
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Taxonomy #2
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Taxonomy Code | 376J00000X
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Taxonomy Name | Homemaker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 376K00000X
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Taxonomy Name | Nurse's Aide
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License Number | 120514E
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License Number State |
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