Provider Demographics
NPI:1851315766
Name:JACKSON, CHARLES W (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5315 N KINGS HWY
Mailing Address - Street 2:PMB 120
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-2534
Mailing Address - Country:US
Mailing Address - Phone:843-503-2000
Mailing Address - Fax:843-272-3032
Practice Address - Street 1:210 UNIVERSITY PLAZA DR
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8978
Practice Address - Country:US
Practice Address - Phone:843-347-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC182103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC182OtherCOUNSELING PSYCHOLOGIST