Provider Demographics
NPI:1013547967
Name:JACKSON, SUNDAY LEE
Entity Type:Individual
Prefix:
First Name:SUNDAY
Middle Name:LEE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:DUNCANSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16635-1338
Mailing Address - Country:US
Mailing Address - Phone:814-329-6096
Mailing Address - Fax:
Practice Address - Street 1:1201 BLAIR ST
Practice Address - Street 2:
Practice Address - City:HOLLIDAYSBURG
Practice Address - State:PA
Practice Address - Zip Code:16648-2445
Practice Address - Country:US
Practice Address - Phone:814-696-0289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-20
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP036528L183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARP036528LOtherLICENSE
PARPI013554OtherINJECTION AUTHORIZATION