Provider Demographics
NPI:1356429674
Name:JACKSON, LASANDRA D (MD)
Entity type:Individual
Prefix:
First Name:LASANDRA
Middle Name:D
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 419402
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-9402
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:2755 S HIGHWAY 14
Practice Address - Street 2:SUITE 2200
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-4902
Practice Address - Country:US
Practice Address - Phone:864-849-9555
Practice Address - Fax:864-849-9556
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20289208600000X
VA0101240815208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09633OtherGROUP PTAN
SC202890Medicaid
VAC06695OtherGROUP PTAN
VAC09633OtherGROUP PTAN