Provider Demographics
NPI:1255385738
Name:HAITHCOCK, JACQUELINE DAVIS (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DAVIS
Last Name:HAITHCOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 DANIEL ELLIS DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-3094
Mailing Address - Country:US
Mailing Address - Phone:843-795-8100
Mailing Address - Fax:843-762-3010
Practice Address - Street 1:776 DANIEL ELLIS DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-3094
Practice Address - Country:US
Practice Address - Phone:843-795-8100
Practice Address - Fax:843-762-3010
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16814173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP3214Medicaid
SCG31081Medicare UPIN