Provider Demographics
NPI:1033428933
Name:JACKSON, NINA KATHERINE TRENT (PA-C)
Entity type:Individual
Prefix:
First Name:NINA
Middle Name:KATHERINE TRENT
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:NINA
Other - Middle Name:KATHERINE
Other - Last Name:TRENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-695-6697
Mailing Address - Fax:
Practice Address - Street 1:209 PATEWOOD DR STE 200
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3589
Practice Address - Country:US
Practice Address - Phone:864-522-6630
Practice Address - Fax:864-522-6635
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1563363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1081PAMedicaid
SC1081PAMedicaid