Provider Demographics
NPI:1386322634
Name:JACKSON, CRADEJA SHOVON
Entity type:Individual
Prefix:
First Name:CRADEJA
Middle Name:SHOVON
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 1:715 KING AVE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4332
Mailing Address - Country:US
Mailing Address - Phone:843-319-7055
Mailing Address - Fax:
Practice Address - Street 1:715 KING AVE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4332
Practice Address - Country:US
Practice Address - Phone:843-319-7055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide