Provider Demographics
NPI:1902866965
Name:JACKSON, ALLEN B (MD)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:B
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 13955
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29422-3955
Mailing Address - Country:US
Mailing Address - Phone:843-764-0770
Mailing Address - Fax:843-863-0402
Practice Address - Street 1:8761 DORCHESTER RD STE 100
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7320
Practice Address - Country:US
Practice Address - Phone:843-767-3323
Practice Address - Fax:843-767-4252
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13680207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6738Medicaid
SC136800Medicaid
SCGP6738Medicaid
SCDC5483OtherRAILROAD MEDICARE GROUP
SCGP4032Medicaid
SCGP6738Medicaid