Provider Demographics
NPI:1447581400
Name:JACKSON, PAULA JO (RPH)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:JO
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 1:107 STALLION CIR
Mailing Address - Street 2:
Mailing Address - City:SOCORRO
Mailing Address - State:NM
Mailing Address - Zip Code:87801-4453
Mailing Address - Country:US
Mailing Address - Phone:575-835-8771
Mailing Address - Fax:575-835-8345
Practice Address - Street 1:1202 HIGHWAY 60
Practice Address - Street 2:
Practice Address - City:SOCORRO
Practice Address - State:NM
Practice Address - Zip Code:87801-3914
Practice Address - Country:US
Practice Address - Phone:575-835-8771
Practice Address - Fax:575-835-8345
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM4257183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist