Provider Demographics
NPI:1144568536
Name:JACKSON, JACINTA E
Entity Type:Individual
Prefix:DR
First Name:JACINTA
Middle Name:E
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 1:303 CHARLIE WATTS DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-4907
Mailing Address - Country:US
Mailing Address - Phone:770-443-4886
Mailing Address - Fax:
Practice Address - Street 1:303 CHARLIE WATTS DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-4907
Practice Address - Country:US
Practice Address - Phone:770-443-4886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-21
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH024544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist