Provider Demographics
NPI:1437436060
Name:JACKSON, DANIEL (RPH)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:JACKSON
Suffix:
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 1:6839 S WESTNEDGE AVE
Mailing Address - Street 2:T-0604
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-3582
Mailing Address - Country:US
Mailing Address - Phone:269-327-9646
Mailing Address - Fax:269-327-9646
Practice Address - Street 1:6839 S WESTNEDGE AVE
Practice Address - Street 2:T-0604
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-3582
Practice Address - Country:US
Practice Address - Phone:269-327-9646
Practice Address - Fax:269-327-9646
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027655183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist