Provider Demographics
NPI:1538177860
Name:JACKSON, WILLIAM G (CRNA)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:G
Last Name:JACKSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1148 DAWN VIEW TERRACE
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4696
Mailing Address - Country:US
Mailing Address - Phone:843-856-9960
Mailing Address - Fax:843-856-9699
Practice Address - Street 1:302 UNIVERSITY PKWY
Practice Address - Street 2:AIKEN REGIONAL MEDICAL CENTER
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801
Practice Address - Country:US
Practice Address - Phone:803-641-5489
Practice Address - Fax:803-651-5148
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN2614367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0080Medicaid
Q27272Medicare UPIN