Provider Demographics
NPI:1811511199
Name:JACKSON, SAMUEL COLLINS (DPT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:COLLINS
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 N RHETT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-4219
Mailing Address - Country:US
Mailing Address - Phone:843-804-9478
Mailing Address - Fax:843-804-9020
Practice Address - Street 1:1125 LANDAU LN
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7300
Practice Address - Country:US
Practice Address - Phone:843-375-5448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
SC10222225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist