Provider Demographics
NPI:1194454413
Name:KEY, JACKIE FITZGERALD II (ABOC, NCLEC, LDO)
Entity type:Individual
Prefix:MR
First Name:JACKIE
Middle Name:FITZGERALD
Last Name:KEY
Suffix:II
Gender:M
Credentials:ABOC, NCLEC, LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 EDGEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-9279
Mailing Address - Country:US
Mailing Address - Phone:803-613-3087
Mailing Address - Fax:803-202-7293
Practice Address - Street 1:1041 EDGEFIELD RD
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29860-9279
Practice Address - Country:US
Practice Address - Phone:803-613-3087
Practice Address - Fax:803-202-7293
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1173156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician