Provider Demographics
NPI:1609231810
Name:JACKSON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
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 1:421 MARY ESTHER CUT OFF NW
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-4084
Mailing Address - Country:US
Mailing Address - Phone:850-301-1334
Mailing Address - Fax:850-301-1339
Practice Address - Street 1:421 MARY ESTHER CUT OFF NW
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-4084
Practice Address - Country:US
Practice Address - Phone:850-301-1334
Practice Address - Fax:850-301-1339
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS32321183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist