Provider Demographics
NPI:1245291954
Name:JACKSON, ANDREW DAN (DC)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:DAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1127
Mailing Address - Country:US
Mailing Address - Phone:843-332-6151
Mailing Address - Fax:844-270-8009
Practice Address - Street 1:1025 W CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4427
Practice Address - Country:US
Practice Address - Phone:843-332-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2881111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC200543021OtherBC/BS
SCCH2881Medicaid
SCU98093Medicare UPIN
SCAA02597836Medicare PIN