Provider Demographics
NPI:1760471130
Name:JACKSON, WILLIAM A JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:MD
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:843-839-1201
Mailing Address - Fax:843-839-1202
Practice Address - Street 1:945 82ND PKWY
Practice Address - Street 2:STE 3B
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4612
Practice Address - Country:US
Practice Address - Phone:843-839-1201
Practice Address - Fax:843-839-1202
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21136207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC211363Medicaid
I03583Medicare UPIN
SC211363Medicaid