Provider Demographics
NPI:1750687513
Name:JACKSON, BRANDY (DC)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DC
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 125
Mailing Address - Street 2:
Mailing Address - City:WAGENER
Mailing Address - State:SC
Mailing Address - Zip Code:29164-0125
Mailing Address - Country:US
Mailing Address - Phone:803-564-6000
Mailing Address - Fax:803-564-6011
Practice Address - Street 1:147 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WAGENER
Practice Address - State:SC
Practice Address - Zip Code:29164-9442
Practice Address - Country:US
Practice Address - Phone:803-564-6000
Practice Address - Fax:803-564-6011
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3479111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor