Provider Demographics
NPI:1154447076
Name:JACKSON, JAMES D JR (RPH)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:D
Last Name:JACKSON
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:JIM
Other - Middle Name:D
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:1040 COUNTY ROAD 225
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:MS
Mailing Address - Zip Code:38683-9279
Mailing Address - Country:US
Mailing Address - Phone:662-223-6659
Mailing Address - Fax:
Practice Address - Street 1:28271 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:MS
Practice Address - Zip Code:38683-8930
Practice Address - Country:US
Practice Address - Phone:662-223-4727
Practice Address - Fax:662-223-5899
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-08477183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist