Provider Demographics
NPI:1003429259
Name:JACKSON, MARY TAYLOR (FNP)
Entity Type:Individual
Prefix:
First Name:MARY TAYLOR
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARY TAYLOR
Other - Middle Name:
Other - Last Name:BRITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8121 ROURK ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4128
Mailing Address - Country:US
Mailing Address - Phone:843-692-5000
Mailing Address - Fax:843-692-5010
Practice Address - Street 1:8121 ROURK ST
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4128
Practice Address - Country:US
Practice Address - Phone:843-692-5000
Practice Address - Fax:843-692-5010
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC24213363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC24213OtherNURSE PRACTITIONER STATE LICENSE