Provider Demographics
NPI:1962023697
Name:MCRAE, JACKSON LANE (RN, BSN)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:LANE
Last Name:MCRAE
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:DARLINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29532-3304
Mailing Address - Country:US
Mailing Address - Phone:843-398-4400
Mailing Address - Fax:843-398-4418
Practice Address - Street 1:305 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:DARLINGTON
Practice Address - State:SC
Practice Address - Zip Code:29532-3304
Practice Address - Country:US
Practice Address - Phone:843-398-4400
Practice Address - Fax:843-398-4418
Is Sole Proprietor?:No
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC232265163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health