Provider Demographics
NPI:1245822733
Name:JONES-MACK, BRANDY
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:JONES-MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 MELBOURNE LN
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29301-3245
Mailing Address - Country:US
Mailing Address - Phone:864-504-7184
Mailing Address - Fax:
Practice Address - Street 1:410 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1933
Practice Address - Country:US
Practice Address - Phone:864-504-7184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-07
Last Update Date:2021-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC78742174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist