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General NPI Number Information
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NPI Number | 1588274765
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Entity Type | Individual
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Provider Name | TOMEKA NICHOLE JACKSON FNP-C
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Gender | Female
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Dates
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Enumeration Date | 08/03/2020
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Last Update Date | 03/03/2022
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Provider Practice Location Address
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Address Line | 6156 SAINT ANDREWS RD STE 208
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City | COLUMBIA
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State | SC
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Zip | 29212-3147
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Country | US
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Telephone | 803-667-9012
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Fax |
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Provider Business Mailing Address
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Address Line | 119 DUTCH VILLAGE DR
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City | IRMO
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State | SC
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Zip | 29063-8718
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Country | US
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Telephone | 803-767-0808
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 22632
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License Number State | SC
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