Provider Demographics
NPI:1215978044
Name:JACKSON, MARYLEE (PA)
Entity type:Individual
Prefix:
First Name:MARYLEE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA
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 25039
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29616-0039
Mailing Address - Country:US
Mailing Address - Phone:864-233-4349
Mailing Address - Fax:864-232-8103
Practice Address - Street 1:3 SAINT FRANCIS DR STE 360
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3972
Practice Address - Country:US
Practice Address - Phone:864-232-4349
Practice Address - Fax:864-233-8103
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8826183500000X
SC509363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0037PAMedicaid
SC3337PAMedicaid