Provider Demographics
NPI:1578814109
Name:JACKSON, JACQUES LEO (DPH)
Entity Type:Individual
Prefix:
First Name:JACQUES
Middle Name:LEO
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 DONELSON PIKE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37214-3729
Mailing Address - Country:US
Mailing Address - Phone:615-889-2511
Mailing Address - Fax:615-316-0559
Practice Address - Street 1:530 DONELSON PIKE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37214-3729
Practice Address - Country:US
Practice Address - Phone:615-889-2511
Practice Address - Fax:615-316-0559
Is Sole Proprietor?:No
Enumeration Date:2012-09-22
Last Update Date:2012-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist