Provider Demographics
NPI:1093878191
Name:JACKSON, LARRY RANDOLPH (REGISTERED NURSE)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:RANDOLPH
Last Name:JACKSON
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:MR
Other - First Name:LARRY
Other - Middle Name:RANDOLPH
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:615 RAPIDS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-3024
Mailing Address - Country:US
Mailing Address - Phone:803-798-2211
Mailing Address - Fax:
Practice Address - Street 1:615 RAPIDS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-3024
Practice Address - Country:US
Practice Address - Phone:803-798-2211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC56879163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health