=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508397548
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAQUINDA JACKSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2017
-----------------------------------------------------
Last Update Date | 05/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 638 TIMBER WALK DR
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-4554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-451-9443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 309 SE MAIN ST SUITE 207
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-2653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-451-9443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 6505
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------