Provider Demographics
NPI:1568542017
Name:JACKSON, LUCILLE
Entity Type:Individual
Prefix:MISS
First Name:LUCILLE
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3502 W NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39213-4454
Mailing Address - Country:US
Mailing Address - Phone:601-362-5321
Mailing Address - Fax:601-364-5193
Practice Address - Street 1:3502 W NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-4454
Practice Address - Country:US
Practice Address - Phone:601-362-5321
Practice Address - Fax:601-364-5193
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR07490183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS2518794OtherNABP