1649230715 NPI number — CHARLES STEVEN JACKSON PA-C

Table of content: CHARLES STEVEN JACKSON PA-C (NPI 1649230715)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649230715 NPI number — CHARLES STEVEN JACKSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACKSON
Provider First Name:
CHARLES
Provider Middle Name:
STEVEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649230715
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 E MCBEE AVE FL 4
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENVILLE
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29601-2842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-797-6306
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10630 CLEMSON BLVD
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
SENECA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29678-4546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-482-6000
Provider Business Practice Location Address Fax Number:
864-482-7166
Provider Enumeration Date:
03/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  377 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 377 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 990013229 . This is a "RR MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 2217PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0041PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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