Provider Demographics
NPI:1861835860
Name:JACKSON, KATHY MELTON (RN)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:MELTON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6051 WESCOTT RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-1408
Mailing Address - Country:US
Mailing Address - Phone:803-476-3609
Mailing Address - Fax:803-476-3620
Practice Address - Street 1:6051 WESCOTT RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1408
Practice Address - Country:US
Practice Address - Phone:803-476-3609
Practice Address - Fax:803-476-3620
Is Sole Proprietor?:No
Enumeration Date:2013-04-10
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29074163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool