Provider Demographics
NPI:1770662967
Name:JACKSON, RANDY
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
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 1:200 MCGEE RD
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29625-2104
Mailing Address - Country:US
Mailing Address - Phone:864-260-2220
Mailing Address - Fax:864-260-2225
Practice Address - Street 1:200 MCGEE RD
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625-2104
Practice Address - Country:US
Practice Address - Phone:864-260-2220
Practice Address - Fax:864-260-2225
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health