Provider Demographics
NPI:1669057121
Name:JACKSON, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
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:PO BOX 643
Mailing Address - Street 2:
Mailing Address - City:BOWMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29018-0643
Mailing Address - Country:US
Mailing Address - Phone:803-354-1011
Mailing Address - Fax:
Practice Address - Street 1:920 LAURA ST
Practice Address - Street 2:
Practice Address - City:BOWMAN
Practice Address - State:SC
Practice Address - Zip Code:29018-8612
Practice Address - Country:US
Practice Address - Phone:803-354-1011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC100078163WH0500X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0500XNursing Service ProvidersRegistered NurseHemodialysis
No163W00000XNursing Service ProvidersRegistered Nurse