Provider Demographics
NPI:1154728319
Name:JACKSON, KATHY LACOLE (RN, BSN)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:LACOLE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:LACOLE
Other - Last Name:HUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN
Mailing Address - Street 1:151 E WOOD ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:151 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3016
Practice Address - Country:US
Practice Address - Phone:864-596-3337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare