Provider Demographics
NPI:1073237350
Name:ANDERSON JACKSON, CELIA
Entity Type:Individual
Prefix:MS
First Name:CELIA
Middle Name:
Last Name:ANDERSON JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1444 DRY BRANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:SC
Mailing Address - Zip Code:29061
Mailing Address - Country:US
Mailing Address - Phone:803-875-1896
Mailing Address - Fax:
Practice Address - Street 1:1444 DRY BRANCH ROAD
Practice Address - Street 2:
Practice Address - City:HOPKINS
Practice Address - State:SC
Practice Address - Zip Code:29061
Practice Address - Country:US
Practice Address - Phone:803-875-1896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-29
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities