Provider Demographics
NPI:1720883093
Name:PURVIS, JACKSON COHEN
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:COHEN
Last Name:PURVIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4630 ARMFIELD RD
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:SC
Mailing Address - Zip Code:29541-5043
Mailing Address - Country:US
Mailing Address - Phone:843-621-1327
Mailing Address - Fax:
Practice Address - Street 1:851 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2632
Practice Address - Country:US
Practice Address - Phone:843-777-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29995363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty