Provider Demographics
NPI:1528032208
Name:JACKSON, WILLIAM HENRY JR (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:HENRY
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD, MBA
Other - Prefix:
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Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD FL 1
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-455-7899
Practice Address - Fax:864-455-5474
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA35913207P00000X
SC38696207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF33494Medicare UPIN