Provider Demographics
NPI:1265086953
Name:JACKSON, KIRSTIE BROOKE
Entity type:Individual
Prefix:
First Name:KIRSTIE
Middle Name:BROOKE
Last Name:JACKSON
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 1:258 QUAIL RD
Mailing Address - Street 2:
Mailing Address - City:GRAY COURT
Mailing Address - State:SC
Mailing Address - Zip Code:29645-4253
Mailing Address - Country:US
Mailing Address - Phone:864-640-3837
Mailing Address - Fax:
Practice Address - Street 1:41 PARK CREEK DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4270
Practice Address - Country:US
Practice Address - Phone:864-299-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC48357164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse