Provider Demographics
NPI:1225627383
Name:SOUTHERLAND, JESSICA IVY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:IVY
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 MITCHELL BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2043
Mailing Address - Country:US
Mailing Address - Phone:706-850-4955
Mailing Address - Fax:706-850-4958
Practice Address - Street 1:240 MITCHELL BRIDGE RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2043
Practice Address - Country:US
Practice Address - Phone:706-850-4955
Practice Address - Fax:706-850-4958
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH031981183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist