Provider Demographics
NPI:1912923996
Name:JACKSON, LISA CHANEL (MD)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:CHANEL
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:SC
Mailing Address - Zip Code:29936-2605
Mailing Address - Country:US
Mailing Address - Phone:843-987-7400
Mailing Address - Fax:
Practice Address - Street 1:1264 RIBAUT RD STE 200
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902-6127
Practice Address - Country:US
Practice Address - Phone:843-524-2466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113699207V00000X
SC33355207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113699Medicaid
IL036113699Medicaid