Provider Demographics
NPI:1326312281
Name:JACKS, BRENDA LEE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LEE
Last Name:JACKS
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 1:7700 NE HIGHWAY 99
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98665-8872
Mailing Address - Country:US
Mailing Address - Phone:360-699-8133
Mailing Address - Fax:360-699-8149
Practice Address - Street 1:7700 NE HIGHWAY 99
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8872
Practice Address - Country:US
Practice Address - Phone:360-699-8133
Practice Address - Fax:360-699-8149
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA58046183500000X
OR8575183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist