Provider Demographics
NPI:1346562055
Name:JACKSON, J.C. JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:J.C.
Middle Name:
Last Name:JACKSON
Suffix:JR
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 1:13415 WOODFOREST BLVD
Mailing Address - Street 2:STE. F
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-2922
Mailing Address - Country:US
Mailing Address - Phone:713-330-4400
Mailing Address - Fax:713-330-4406
Practice Address - Street 1:13415 WOODFOREST BLVD
Practice Address - Street 2:STE. F
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-2922
Practice Address - Country:US
Practice Address - Phone:713-330-4400
Practice Address - Fax:713-330-4406
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25389183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1699814962Medicaid