Provider Demographics
NPI:1417957895
Name:JACKSON, LONNIE L
Entity Type:Individual
Prefix:MR
First Name:LONNIE
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8414 GLENCROSS ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77061-2314
Mailing Address - Country:US
Mailing Address - Phone:713-204-7443
Mailing Address - Fax:
Practice Address - Street 1:2015 THOMAS ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77009-8044
Practice Address - Country:US
Practice Address - Phone:713-873-4014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist