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General NPI Number Information
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NPI Number | 1588293278
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Entity Type | Individual
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Provider Name | KIMBERLY DIANNE BILLIE JACKSON AGNP-C
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Gender | Female
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Dates
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Enumeration Date | 04/04/2020
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Last Update Date | 12/27/2021
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Provider Practice Location Address
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Address Line | 940 MORNINGSIDE DR
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City | SUMTER
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State | SC
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Zip | 29153-7724
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Country | US
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Telephone | 914-359-7442
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Fax | 803-883-4087
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Provider Business Mailing Address
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Address Line | PO BOX 141
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City | SUMTER
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State | SC
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Zip | 29151-0141
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Country | US
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Telephone | 914-359-7442
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Fax | 803-883-4087
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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 | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 23707
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number | APN.23707
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License Number State | SC
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Taxonomy #3
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | APN.23707
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License Number State | SC
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