Provider Demographics
NPI:1588293278
Name:JACKSON, KIMBERLY DIANNE BILLIE (AGNP-C)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANNE BILLIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:DIANNE
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 141
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29151-0141
Mailing Address - Country:US
Mailing Address - Phone:914-359-7442
Mailing Address - Fax:803-883-4087
Practice Address - Street 1:940 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29153-7724
Practice Address - Country:US
Practice Address - Phone:914-359-7442
Practice Address - Fax:803-883-4087
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-04
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23707291U00000X
SCAPN.23707261QC1500X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No291U00000XLaboratoriesClinical Medical Laboratory
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AG01200075OtherAANP CERTIFICATION NUMBER
AG01200075OtherAMERICAN ASSOCIATION OF NURSE PRACTITIONERS CERTIFYING BOARD