Provider Demographics
NPI:1578157442
Name:JACKSON, GRAYSON (PT)
Entity Type:Individual
Prefix:
First Name:GRAYSON
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:GRAYSON
Other - Middle Name:
Other - Last Name:GRAINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:141 ATRIUM WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6301
Mailing Address - Country:US
Mailing Address - Phone:843-388-7667
Mailing Address - Fax:843-388-7877
Practice Address - Street 1:3040 HIGHWAY 17 BYP N STE A
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-9438
Practice Address - Country:US
Practice Address - Phone:843-388-7667
Practice Address - Fax:843-388-7877
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10570225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist