Provider Demographics
NPI:1376264192
Name:DEWALT, JACKARA SHADASHA
Entity Type:Individual
Prefix:
First Name:JACKARA
Middle Name:SHADASHA
Last Name:DEWALT
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 1:325 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29306-5231
Mailing Address - Country:US
Mailing Address - Phone:803-290-0522
Mailing Address - Fax:
Practice Address - Street 1:1600 PLATT SPRINGS RD APT 34
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-5542
Practice Address - Country:US
Practice Address - Phone:803-290-0522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator