Provider Demographics
NPI:1356003552
Name:JACKSON, TREVOR BRANDON (MT)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:BRANDON
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8117 SPRINGFLOWER ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223
Mailing Address - Country:US
Mailing Address - Phone:254-462-3790
Mailing Address - Fax:
Practice Address - Street 1:1631 MAIN ST COLUMBIA SC
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223
Practice Address - Country:US
Practice Address - Phone:803-310-2793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10033225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist