Provider Demographics
NPI:1255840773
Name:JACKSON, HALEY MEHARG (CPNP)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:MEHARG
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:HALEY
Other - Middle Name:AMANDA
Other - Last Name:MEHARG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:360 N IRBY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-2808
Mailing Address - Country:US
Mailing Address - Phone:843-667-9414
Mailing Address - Fax:
Practice Address - Street 1:1920 2ND LOOP RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-6123
Practice Address - Country:US
Practice Address - Phone:843-432-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21336363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics