Provider Demographics
NPI:1104190990
Name:JACKSON, JARRYD A (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JARRYD
Middle Name:A
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 JACKSON ST NE
Mailing Address - Street 2:UNIT #3412
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-1303
Mailing Address - Country:US
Mailing Address - Phone:404-583-1379
Mailing Address - Fax:
Practice Address - Street 1:1265 HIGHWAY 54 W
Practice Address - Street 2:SUITE #201
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4548
Practice Address - Country:US
Practice Address - Phone:678-435-3046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH024513183500000X
FLPS42485183500000X
TX46840183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist