Provider Demographics
NPI:1932846649
Name:JACKSON, SANDRA DENISE
Entity Type:Individual
Prefix:MISS
First Name:SANDRA
Middle Name:DENISE
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 1:1150 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-1997
Mailing Address - Country:US
Mailing Address - Phone:803-566-3921
Mailing Address - Fax:
Practice Address - Street 1:1150 BROAD ST STE 4
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1997
Practice Address - Country:US
Practice Address - Phone:803-869-1005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-14
Last Update Date:2022-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLI-234264251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health