Keelan Raphael Jackson

Primary specialty

Independent Duty CorpsmanTaxonomy code 1710I1002X

License

1790449882 Issued in SC

Practice address

670 Boulevard de France
Parris Island, SC 29905

Phone

(843) 228-4757

NPI assigned

Oct 26, 2021

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

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

{
    "created_epoch": "1635206400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1785801600000",
    "number": "1790449882",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "670 BOULEVARD DE FRANCE",
            "city": "PARRIS ISLAND",
            "state": "SC",
            "postal_code": "29905",
            "telephone_number": "843-228-4757"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "670 BOULEVARD DE FRANCE",
            "city": "PARRIS ISLAND",
            "state": "SC",
            "postal_code": "29905",
            "telephone_number": "843-228-4757"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACKSON",
        "first_name": "KEELAN",
        "middle_name": "RAPHAEL",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-10-26",
        "last_updated": "2026-08-04",
        "certification_date": "2026-08-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1710I1002X",
            "taxonomy_group": "",
            "desc": "Military Health Care Provider, Independent Duty Corpsman",
            "state": "SC",
            "license": "1790449882",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jocelyn Marie Herman, O.D.
• Andrew Holderer, DMD
• Euneece Hong
• Kendra Ireigbe, PA-C
• Paige Jablon, DDS
• Jeremiah Raeman Juarez, DMD
• Mitchell Patrick Kellerman, D.D.S.
• Daniel James Lange
• Josh E Lundgaard, ATC, CSCS
• Jeffrey Magin, DMD

• Independent Duty Corpsman in Parris Island, SC
• Providers in Parris Island, SC by specialty
• Independent Duty Corpsman in South Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 4, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.