Provider Demographics
NPI:1962981142
Name:JACKSON PEDIATRIC DENTISTRY OF SUMMERVILLE
Entity type:Organization
Organization Name:JACKSON PEDIATRIC DENTISTRY OF SUMMERVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:910-620-7881
Mailing Address - Street 1:303 BRANCH CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-5338
Mailing Address - Country:US
Mailing Address - Phone:910-620-7881
Mailing Address - Fax:
Practice Address - Street 1:405 WEST 4TH STREET NORTH
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483
Practice Address - Country:US
Practice Address - Phone:843-376-3161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-09
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX8666Medicaid