Provider Demographics
NPI:1265113054
Name:JACKSON, PORTIA GOODE
Entity type:Individual
Prefix:
First Name:PORTIA
Middle Name:GOODE
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 1:887 PINE LOG FORD RD
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-8418
Mailing Address - Country:US
Mailing Address - Phone:803-467-8687
Mailing Address - Fax:
Practice Address - Street 1:887 PINE LOG FORD RD
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-8418
Practice Address - Country:US
Practice Address - Phone:803-467-8687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC01328980342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company