Provider Demographics
NPI:1386984284
Name:JACKSON, CAROLYN ANN (RN, BSN)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-2855
Mailing Address - Country:US
Mailing Address - Phone:843-774-1227
Mailing Address - Fax:843-841-3601
Practice Address - Street 1:926 PERRY AVE
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-4734
Practice Address - Country:US
Practice Address - Phone:843-774-1227
Practice Address - Fax:843-774-3601
Is Sole Proprietor?:No
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC70371163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool