Provider Demographics
NPI:1144756883
Name:JACKSON, GERALD ALLEN
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:ALLEN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GERALD
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARMD
Mailing Address - Street 1:2121 MARIGOLD ST
Mailing Address - Street 2:
Mailing Address - City:LEWIS CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43035-7368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 MARIGOLD ST
Practice Address - Street 2:
Practice Address - City:LEWIS CENTER
Practice Address - State:OH
Practice Address - Zip Code:43035-7368
Practice Address - Country:US
Practice Address - Phone:614-562-9101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03331193183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist