Provider Demographics
NPI:1114286150
Name:JACKSON, CHRISTINE STEVENS
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:STEVENS
Last Name: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 1:161 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:MC CLELLANVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29458-9721
Mailing Address - Country:US
Mailing Address - Phone:843-230-9297
Mailing Address - Fax:
Practice Address - Street 1:161 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:MC CLELLANVILLE
Practice Address - State:SC
Practice Address - Zip Code:29458-9721
Practice Address - Country:US
Practice Address - Phone:843-230-9297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-11
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1600246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory