Provider Demographics
NPI:1346692548
Name:JACKSON, MARSHA LYNN
Entity Type:Individual
Prefix:
First Name:MARSHA
Middle Name:LYNN
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:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512
Mailing Address - Country:US
Mailing Address - Phone:843-454-0841
Mailing Address - Fax:
Practice Address - Street 1:207 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:SC
Practice Address - Zip Code:29709
Practice Address - Country:US
Practice Address - Phone:843-623-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid