Provider Demographics
NPI:1235414202
Name:JACKSON, JEROME SEAN (RPH)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:SEAN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 WALDWAY LANE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45224
Mailing Address - Country:US
Mailing Address - Phone:513-542-1706
Mailing Address - Fax:
Practice Address - Street 1:1198 W. KEMPER ROAD
Practice Address - Street 2:WALGREENS
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45224
Practice Address - Country:US
Practice Address - Phone:513-851-0205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-20
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03217734183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist