Provider Demographics
NPI:1124476510
Name:HENRY, SANDRA JACKSON
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:JACKSON
Last Name:HENRY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:SANDRA
Other - Middle Name:SABRINA
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1735 SAINT JULIAN PL STE 300
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2402
Mailing Address - Country:US
Mailing Address - Phone:803-708-5081
Mailing Address - Fax:
Practice Address - Street 1:879 NE MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-2056
Practice Address - Country:US
Practice Address - Phone:864-688-9416
Practice Address - Fax:844-300-6266
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8841101Y00000X, 101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional