Provider Demographics
NPI:1649230715
Name:JACKSON, CHARLES STEVEN (PA-C)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:STEVEN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:864-797-6306
Mailing Address - Fax:
Practice Address - Street 1:10630 CLEMSON BLVD
Practice Address - Street 2:STE 100
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-4546
Practice Address - Country:US
Practice Address - Phone:864-482-6000
Practice Address - Fax:864-482-7166
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC377363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC990013229OtherRR MEDICARE
SC2217PAMedicaid
SC0041PAMedicaid
SC0041PAMedicaid