Individual
KEELAN RAPHAEL JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
670 BOULEVARD DE FRANCE, PARRIS ISLAND, SC 29905
(843) 228-4757
Mailing address
670 BOULEVARD DE FRANCE, PARRIS ISLAND, SC 29905
(843) 228-4757
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
1790449882
SC
1710I1002X
Independent Duty Corpsman
Primary
—
CA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
10/26/2021
Last updated
08/04/2026
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