Provider Demographics
NPI:1124538285
Name:LAXTON, JACQUELINE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:LAXTON
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 1:27 OUTPOST LN
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29928-3821
Mailing Address - Country:US
Mailing Address - Phone:843-816-2410
Mailing Address - Fax:
Practice Address - Street 1:38 SHERIDAN PARK CIR STE C
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-7023
Practice Address - Country:US
Practice Address - Phone:843-815-5628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3795208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation