Provider Demographics
NPI:1346465861
Name:JACKS, SUSAN J (RPH)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
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 1:222 BELL LN STE 5A
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-6303
Mailing Address - Country:US
Mailing Address - Phone:318-988-3018
Mailing Address - Fax:318-988-3020
Practice Address - Street 1:222 BELL LN STE 5A
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-6303
Practice Address - Country:US
Practice Address - Phone:318-988-3018
Practice Address - Fax:318-988-3020
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11518183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist