Basic Information
| Provider Information | |||||||||
| NPI: | 1821480195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COUNCIL | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | ANGELA | ||||||||
| OtherMiddleName: | JETT | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1090 | ||||||||
| Address2: | |||||||||
| City: | HARTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295511090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438570111 | ||||||||
| FaxNumber: | 8438570206 | ||||||||
| Practice Location | |||||||||
| Address1: | 1268 S 4TH ST | ||||||||
| Address2: | |||||||||
| City: | HARTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295500703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433323422 | ||||||||
| FaxNumber: | 8433323985 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2015 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 19322 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NP3277 | 05 | SC | MEDICAID |