NPIMap

Individual provider Active NPI

Kimberly Shelley Jackson, M.D.

  • Family Medicine Physician
  • Daniel Island, SC
National Provider Identifier
1558318527
Registry record updated Jan 23, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
18009 Issued in SC
Practice address
864 Island Park Dr Ste 101
Daniel Island, SC 29492-7446
Phone
(843) 876-7975
NPI assigned
May 27, 2006
Last updated
Jan 23, 2019By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 23, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 18009 SC Primary

Addresses

Primary practice location

864 Island Park Dr Ste 101
Daniel Island, SC 29492-7446

Mailing address

PO Box 602108
Charlotte, NC 28260-2108
Phone (843) 792-6200

Other practice location 1

1210 Main St
Conway, SC 29526-3633
Phone (843) 488-1700

Other practice location 2

800 E Cheves St Ste 200
Florence, SC 29506-2651
Phone (843) 662-1502

Other practice location 3

1113 Parkwest Blvd
Mt Pleasant, SC 29466
Phone (843) 876-1445

Other identifiers 1

IdentifierTypeStateIssuer
T19753MedicaidSC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in SC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20040824000038 SC Practitioner - Family Practice 1759355357 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of South Carolina School of Medicine, 1994
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Carolina Family Care IncGroup PAC ID 4587557731, 81 clinicians

Practice addresses (Care Compare)

1113 Park W Blvd
Mount Pleasant, SC 29466-7121
Phone (843) 876-1445

Hospital & facility affiliations

Merit-based Incentive Payment System (MIPS)

Final score
90.15 of 100Reported as group
Quality
83.18
Promoting interoperability
98
Improvement activities
40

Merit-based Incentive Payment System (MIPS)

Final score
93.96 of 100Reported as group
Quality
89.02
Promoting interoperability
100
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Carolina Family Care, Inc Family Medicine CurrentSince Jan 14, 2019 Accepting new patients
Rivertown Family Medicine, P.C. Family Medicine CurrentSince Sep 16, 2004 Accepting new patients
Carolina Family Care, Inc Family Medicine CurrentSince Jan 14, 2019 Accepting new patients
Medical University Hospital Authority CurrentSince Dec 1, 2020 Accepting new patients
Medical University Hospital Authority Current Accepting new patients
Medical University Hospital Authority CurrentSince Dec 1, 2020 Accepting new patients
Carolina Family Care, Inc Past Accepting new patients

Locations

1 Medical Park Dr
Chester, SC 29706
Phone (803) 581-3151

1210 Main St
Conway, SC 29526
Phone (843) 488-1700

864 Island Park Dr
Ste 101
Daniel Island, SC 29492
Phone (843) 792-4500

1113 Park West Blvd
Mt Pleasant, SC 29466
Phone (843) 876-1445

1208 Two Island Ct
Mt Pleasant, SC 29466
Phone (843) 884-6653

1341 Old Georgetown Rd
Ste C
Mt Pleasant, SC 29464
Phone (843) 884-2175

2845 E Highway 76
Ste 5
Mullins, SC 29574
Phone (843) 431-2280

511 S Main St
Mullins, SC 29574
Phone (843) 464-8244

Interoperability endpoints

  • Direct secure messaging: kjackson250609@direct.musc.edu

Organizations & group practices 7

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 11

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1148688000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1548201600000",
    "number": "1558318527",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 602108",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282602108",
            "telephone_number": "843-792-6200"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "864 ISLAND PARK DR STE 101",
            "city": "DANIEL ISLAND",
            "state": "SC",
            "postal_code": "294927446",
            "telephone_number": "843-876-7975"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1210 Main St",
            "address_purpose": "LOCATION",
            "city": "Conway",
            "state": "SC",
            "postal_code": "295263633",
            "country_code": "US",
            "telephone_number": "843-488-1700",
            "fax_number": "843-488-4301",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "800 E Cheves St Ste 200",
            "address_purpose": "LOCATION",
            "city": "Florence",
            "state": "SC",
            "postal_code": "295062651",
            "country_code": "US",
            "telephone_number": "843-662-1502",
            "fax_number": "843-678-3611",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1113 Parkwest Blvd",
            "address_purpose": "LOCATION",
            "city": "Mt Pleasant",
            "state": "SC",
            "postal_code": "29466",
            "country_code": "US",
            "telephone_number": "843-876-1445",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KIMBERLY",
        "middle_name": "SHELLEY",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-05-27",
        "last_updated": "2019-01-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "SC",
            "license": "18009",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "T19753",
            "state": "SC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Daniel Island, SC

Sources for this page

Verify at the official NPI Registry.