Provider Demographics
NPI:1407034390
Name:JACKSON, WENDY M (RPH)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:M
Last Name:JACKSON
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 1:11085 LITTLE PATUXENT PKWY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-2983
Mailing Address - Country:US
Mailing Address - Phone:410-997-1600
Mailing Address - Fax:410-997-4732
Practice Address - Street 1:11085 LITTLE PATUXENT PKWY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-2983
Practice Address - Country:US
Practice Address - Phone:410-997-1600
Practice Address - Fax:410-997-4732
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-04
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13597183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist