Basic Information
| Provider Information | |||||||||
| NPI: | 1861643389 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | TRACEY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2413 CEDAR SPGS S | ||||||||
| Address2: | |||||||||
| City: | ABBEVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296206246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644463407 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1547 PARKWAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296464081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642297120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2008 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 421504 | 05 | SC | MEDICAID |