Active NPI
Marc Ryan Jackson, MD
- Psychiatry Physician
- Charleston, SC
National Provider Identifier
1730970229
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychiatry Physician
- License
- LL94479
- Practice address
- 67 President St
Charleston, SC 29425-5712 - Phone
- (843) 792-0192
- NPI assigned
- May 14, 2025
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychiatry Physician | 2084P0800X | LL94479 | SC | Primary |
Addresses
Primary practice location
67 President St
Charleston, SC 29425-5712
Mailing address
169 Ashley Ave RM 202
Charleston, SC 29425-8905
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in SC
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20251023004154 | SC | Order and Referring Only - Psychiatry | 1456849140 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LL94479 | SC | MD | Psychiatry Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1747180800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1750032000000",
"number": "1730970229",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "169 ASHLEY AVE RM 202",
"city": "CHARLESTON",
"state": "SC",
"postal_code": "294258905"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "67 PRESIDENT ST",
"city": "CHARLESTON",
"state": "SC",
"postal_code": "294255712",
"telephone_number": "843-792-0192"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JACKSON",
"first_name": "MARC",
"middle_name": "RYAN",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2025-05-14",
"last_updated": "2025-06-16",
"certification_date": "2025-06-16",
"status": "A"
},
"taxonomies": [
{
"code": "2084P0800X",
"taxonomy_group": "",
"desc": "Psychiatry & Neurology, Psychiatry",
"state": "SC",
"license": "LL94479",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Charleston, SC
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.