Provider Demographics
NPI:1558318527
Name:JACKSON, KIMBERLY SHELLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:SHELLEY
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
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 602108
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2108
Mailing Address - Country:US
Mailing Address - Phone:843-792-6200
Mailing Address - Fax:
Practice Address - Street 1:864 ISLAND PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:DANIEL ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29492-7446
Practice Address - Country:US
Practice Address - Phone:843-876-7975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT19753Medicaid
SCGO47228035Medicare ID - Type UnspecifiedMEDICARE NUMBER
SCT19753Medicaid
SC42D0940858OtherCLIA LABRATORY NUMBER