Provider Demographics
NPI:1093947202
Name:JACKSON, DANIELLE LISETTE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:LISETTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:DANIELLE
Other - Middle Name:LISETTE
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:100 DERBY ST
Mailing Address - Street 2:3210
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043
Mailing Address - Country:US
Mailing Address - Phone:781-749-8730
Mailing Address - Fax:781-749-2356
Practice Address - Street 1:100 DERBY ST
Practice Address - Street 2:
Practice Address - City:HINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02043
Practice Address - Country:US
Practice Address - Phone:781-749-8730
Practice Address - Fax:781-749-2356
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH27101183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist