Provider Demographics
NPI:1609365170
Name:JACKSON, CORY DANIEL
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:DANIEL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 ASHLEY AVENUE
Mailing Address - Street 2:ROOM 202 MAIN HOSPITAL, MSC333
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425
Mailing Address - Country:US
Mailing Address - Phone:518-859-5714
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY AVENUE
Practice Address - Street 2:ROOM 202 MAIN HOSPITAL. MSC 333
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425
Practice Address - Country:US
Practice Address - Phone:843-212-6872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2021-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program