Provider Demographics
NPI:1508014853
Name:STANSBURY, JACK A JR (NP)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:A
Last Name:STANSBURY
Suffix:JR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 NNPTC CIRCLE
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445
Mailing Address - Country:US
Mailing Address - Phone:843-794-6000
Mailing Address - Fax:843-794-6036
Practice Address - Street 1:2550 ELMS CENTER RD
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9844
Practice Address - Country:US
Practice Address - Phone:843-302-8840
Practice Address - Fax:843-818-2188
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19033363LF0000X
LAAP05772363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4330Medicaid