MEDICARE: KIMBERLY JACKSON CNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide	116725E	SC

General Provider Information

NPI Number	:	1972930279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY JACKSON CNA

Provider Business Mailing Address
First Line	:	518 E MAIN ST
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29302-1927
Country	:	US
Telephone Number	:	864-670-0373
Fax Number	:

Provider Business Practice Location Address
First Line	:	518 E MAIN ST
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29302-1927
Country	:	US
Telephone Number	:	864-670-0373
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/01/2013
Last Update Date	:	12/08/2025

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