Basic Information
| Provider Information | |||||||||
| NPI: | 1043459084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKS | ||||||||
| FirstName: | LYLE | ||||||||
| MiddleName: | HENDRICKS | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREENE | ||||||||
| OtherFirstName: | LYLE | ||||||||
| OtherMiddleName: | HENDRICKS | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1807A E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296403841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644427482 | ||||||||
| FaxNumber: | 8643067977 | ||||||||
| Practice Location | |||||||||
| Address1: | 1807A E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296403841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644427482 | ||||||||
| FaxNumber: | 8643067977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2009 | ||||||||
| LastUpdateDate: | 02/16/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 5292 | SC | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.