Provider Demographics
NPI:1407316003
Name:JACKSON, SUSAN (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1022 SEALYHAM CT
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-4763
Mailing Address - Country:US
Mailing Address - Phone:614-208-2241
Mailing Address - Fax:
Practice Address - Street 1:1022 SEALYHAM CT
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-4763
Practice Address - Country:US
Practice Address - Phone:614-208-2241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03117343183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03117343OtherPHARMACIST LICENSE