Provider Demographics
NPI:1225770175
Name:JACKSON, TERI ARLANA
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:ARLANA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LATTA
Mailing Address - State:SC
Mailing Address - Zip Code:29565-1510
Mailing Address - Country:US
Mailing Address - Phone:843-474-1207
Mailing Address - Fax:
Practice Address - Street 1:332 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LATTA
Practice Address - State:SC
Practice Address - Zip Code:29565-1510
Practice Address - Country:US
Practice Address - Phone:843-474-1207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-11
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier