Provider Information for 1508397548
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JAQUINDA JACKSON
Sex: Female
NPI: 1508397548
Last Updated: 2017-05-01
Certification Date:
Certification Date:
Details
| Name | Value | ||||||||
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| NPI | 1508397548 | ||||||||
| Enumeration Date | 2017-03-22 | ||||||||
| NPI Type | NPI-1 Individual | ||||||||
| Sole Proprietor | YES | ||||||||
| Status | Active | ||||||||
| Mailing Address | 309 SE MAIN ST SUITE 207 SIMPSONVILLE, SC 29681-2653 United States Phone: 864-451-9443 | Fax: | ||||||||
| Primary Practice Address | 638 TIMBER WALK DR SIMPSONVILLE, SC 29681-4554 United States Phone: 864-451-9443 | Fax: | ||||||||
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