Provider Demographics
NPI:1841270212
Name:RHYNE, JACK WILSON (LCSW, LISW)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:WILSON
Last Name:RHYNE
Suffix:
Gender:M
Credentials:LCSW, LISW
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 1090
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-1090
Mailing Address - Country:US
Mailing Address - Phone:843-857-0111
Mailing Address - Fax:843-857-0206
Practice Address - Street 1:812 STATE RD
Practice Address - Street 2:
Practice Address - City:CHERAW
Practice Address - State:SC
Practice Address - Zip Code:29520
Practice Address - Country:US
Practice Address - Phone:843-537-0961
Practice Address - Fax:843-537-0908
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0021801041C0700X
SC0048801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
SCSW1107Medicaid
NC1255YOtherBCBS
SCQ357161850Medicare PIN
SC3343Medicare PIN
NC2872238AMedicare ID - Type Unspecified
SCSW1107Medicaid