Basic Information
| Provider Information | |||||||||
| NPI: | 1790386738 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11810 BIRD POINT TRL | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757038104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032837618 | ||||||||
| FaxNumber: | 9035086127 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 ESE LOOP323 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757018337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035086127 | ||||||||
| FaxNumber: | 9035086128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2020 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 46850 | TX | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.