Provider Demographics
NPI:1679193841
Name:JACKSON, MARGARET
Entity Type:Individual
Prefix:
First Name:MARGARET
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 PIEDMONT BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-1836
Mailing Address - Country:US
Mailing Address - Phone:803-327-2012
Mailing Address - Fax:803-327-4198
Practice Address - Street 1:205 PIEDMONT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1836
Practice Address - Country:US
Practice Address - Phone:803-327-2012
Practice Address - Fax:803-327-4198
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC99719163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1568476885Medicaid
SC3339OtherMEDICARE