Provider Demographics
NPI:1215228275
Name:JACKSON-SMALL, BERNADETTE ELISE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:BERNADETTE
Middle Name:ELISE
Last Name:JACKSON-SMALL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5840 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70805-1320
Mailing Address - Country:US
Mailing Address - Phone:225-355-4456
Mailing Address - Fax:225-359-9063
Practice Address - Street 1:5840 PLANK RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70805
Practice Address - Country:US
Practice Address - Phone:225-355-4456
Practice Address - Fax:225-359-9063
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA16937183500000X
AL11393183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist