Provider Demographics
NPI:1164026837
Name:JACKSON, CATIE DIANE (PA-C)
Entity Type:Individual
Prefix:
First Name:CATIE
Middle Name:DIANE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 MOSS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-1923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2720 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4810
Practice Address - Country:US
Practice Address - Phone:803-791-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical