Individual
DR. MITCHELL WELLS JACOCKS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
2728 SUNSET BLVD STE 300, WEST COLUMBIA, SC 29169-4815
(803) 744-4940
(803) 744-4938
Mailing address
PO BOX 6069, WEST COLUMBIA, SC 29171-6069
Taxonomy
Speciality
Code
Description
License number
State
207RC0000X
Cardiovascular Disease Physician
Primary
20836
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CC5386
RRMEDICARE
SC
05
—
T49604
—
SC
Enumeration date
02/09/2006
Last updated
11/06/2020
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