Basic Information
Provider Information | |||||||||
NPI: | 1912923996 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JACKSON | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | CHANEL | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3310 MAGNOLIA ST | ||||||||
Address2: |   | ||||||||
City: | ORANGEBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 291151466 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8035316900 | ||||||||
FaxNumber: | 8035316907 | ||||||||
Practice Location | |||||||||
Address1: | 3310 MAGNOLIA ST | ||||||||
Address2: |   | ||||||||
City: | ORANGEBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 291151466 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8035316900 | ||||||||
FaxNumber: | 8035316907 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2006 | ||||||||
LastUpdateDate: | 05/18/2011 | ||||||||
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 | 207V00000X | 33355 | SC | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   | 207V00000X | 036113699 | IL | N |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 036113699 | 05 | IL |   | MEDICAID |