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General NPI Number Information
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NPI Number | 1871612002
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Entity Type | Individual
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Provider Name | NORWARD EARL JACKSON
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Gender | Male
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 200 CLAUDE BUNDRICK RD KIVA
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City | BLYTHEWOOD
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State | SC
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Zip | 29016-9420
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Country | US
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Telephone | 803-754-5478
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Fax | 803-754-9644
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Provider Business Mailing Address
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Address Line | 817 SETON RD
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City | COLUMBIA
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State | SC
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Zip | 29212-3361
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Country | US
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Telephone | 803-772-4417
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State | SC
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