Provider Demographics
NPI:1679006183
Name:JACKSON, ALLISON
Entity Type:Individual
Prefix:
First Name:ALLISON
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 1:556 NORTHSIDE DR E
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-2191
Mailing Address - Country:US
Mailing Address - Phone:912-489-8683
Mailing Address - Fax:
Practice Address - Street 1:556 NORTHSIDE DR E
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-2191
Practice Address - Country:US
Practice Address - Phone:912-489-8683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH028117183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist