Provider Demographics
NPI:1598033417
Name:JACKSON, KELECHI IHUOMA
Entity Type:Individual
Prefix:
First Name:KELECHI
Middle Name:IHUOMA
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 1:5200 NELSON RD APT 901
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-0814
Mailing Address - Country:US
Mailing Address - Phone:773-931-1930
Mailing Address - Fax:
Practice Address - Street 1:4828 NELSON RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5214
Practice Address - Country:US
Practice Address - Phone:773-931-1930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019657183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist