Provider Demographics
NPI:1932778107
Name:JACKSON, CHARNELE VONTESE
Entity Type:Individual
Prefix:
First Name:CHARNELE
Middle Name:VONTESE
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 1:1712 NICHOLAS DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29154-7909
Mailing Address - Country:US
Mailing Address - Phone:803-316-4581
Mailing Address - Fax:
Practice Address - Street 1:105 N MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4941
Practice Address - Country:US
Practice Address - Phone:803-934-2806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC227658163WC1500X
SC25444363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health