Provider Demographics
NPI:1457703332
Name:PEARSON, JAMEEL
Entity Type:Individual
Prefix:
First Name:JAMEEL
Middle Name:
Last Name:PEARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 N MATTHEWS RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-7027
Mailing Address - Country:US
Mailing Address - Phone:843-394-7600
Mailing Address - Fax:843-394-2603
Practice Address - Street 1:675 N MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-7027
Practice Address - Country:US
Practice Address - Phone:843-394-7600
Practice Address - Fax:843-394-2603
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3337Medicaid
SC3337Medicaid