Provider Demographics
NPI:1609150622
Name:STAFFORD, JACKIE P (DNP)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:P
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:DNP
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-7098
Mailing Address - Fax:843-777-7102
Practice Address - Street 1:710 CHESTERFIELD HWY
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520-7001
Practice Address - Country:US
Practice Address - Phone:843-537-2171
Practice Address - Fax:843-537-5926
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17625363LA2200X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1947Medicaid
SCAA81181850Medicare PIN