Provider Demographics
NPI:1164585790
Name:JACKSON, CLINTONIA (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTONIA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CLINTONIA
Other - Middle Name:
Other - Last Name:BOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3620 PELHAM RD
Mailing Address - Street 2:PMB 145
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-5044
Mailing Address - Country:US
Mailing Address - Phone:321-698-7637
Mailing Address - Fax:307-316-0409
Practice Address - Street 1:5 MEMORIAL MEDICAL CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4449
Practice Address - Country:US
Practice Address - Phone:864-272-3409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66277207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000042300Medicaid
FL25828UMedicare PIN
FL000042300Medicaid
FLF89936Medicare UPIN
FL25828BMedicare PIN