Basic Information
| Provider Information | |||||||||
| NPI: | 1841270212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RHYNE | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | WILSON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LISW | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1090 | ||||||||
| Address2: | |||||||||
| City: | HARTSVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295511090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438570111 | ||||||||
| FaxNumber: | 8438570206 | ||||||||
| Practice Location | |||||||||
| Address1: | 204 PERRY WILEY WAY | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297095701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436235080 | ||||||||
| FaxNumber: | 8436235081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C002180 | NC | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 004880 | SC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | SW1107 | 05 | SC | MEDICAID | 1255Y | 01 | NC | BCBS | OTHER | 405127 | 05 | SC | MEDICAID |