Provider Demographics
NPI:1871612002
Name:JACKSON, NORWARD EARL
Entity type:Individual
Prefix:
First Name:NORWARD
Middle Name:EARL
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 SETON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-3361
Mailing Address - Country:US
Mailing Address - Phone:803-772-4417
Mailing Address - Fax:
Practice Address - Street 1:200 CLAUDE BUNDRICK RD
Practice Address - Street 2:KIVA
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-9420
Practice Address - Country:US
Practice Address - Phone:803-754-5478
Practice Address - Fax:803-754-9644
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health