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General NPI Number Information
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NPI Number | 1548753965
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Entity Type | Individual
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Provider Name | JEFFREY JACKSON LGSW
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Gender | Male
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Dates
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Enumeration Date | 06/11/2018
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Last Update Date | 06/11/2018
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Provider Practice Location Address
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Address Line | 2024 CORPORATE CENTRE DR STE 103
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City | MYRTLE BEACH
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State | SC
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Zip | 29577-7410
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Country | US
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Telephone | 843-232-2441
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Fax |
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Provider Business Mailing Address
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Address Line | 2024 CORPORATE CENTRE DR STE 103
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City | MYRTLE BEACH
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State | SC
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Zip | 29577-7410
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Country | US
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Telephone | 843-232-2441
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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 | 104100000X
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Taxonomy Name | Social Worker
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License Number | 3475G
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License Number State | AL
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