Provider Demographics
NPI:1124049978
Name:JACKSON, WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:JACKSON
Suffix:
Gender:M
Credentials:MD
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1656 RIVERCHASE BLVD
Practice Address - Street 2:SUITE 2400
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2084
Practice Address - Country:US
Practice Address - Phone:803-329-5131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10912207Q00000X
NC9300722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080102868OtherRAILROAD MEDICARE
NC0694ZOtherBLUE CROSS BLUE SHIELD NC
SC109126Medicaid
SCD992524592Medicare PIN
080102868OtherRAILROAD MEDICARE
NC0694ZOtherBLUE CROSS BLUE SHIELD NC