Provider Demographics
NPI:1275514994
Name:JACKSON, KENNETH CONRAD II (PHARMD, RPH)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:CONRAD
Last Name:JACKSON
Suffix:II
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2731 HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3652
Mailing Address - Country:US
Mailing Address - Phone:801-487-2169
Mailing Address - Fax:801-581-6243
Practice Address - Street 1:546 CHIPETA WAY
Practice Address - Street 2:SUITE 220
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1236
Practice Address - Country:US
Practice Address - Phone:801-581-7246
Practice Address - Fax:801-581-6243
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT363584-17011835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy