Provider Demographics
NPI:1750680955
Name:JACKSON, BOBBIE SUE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BOBBIE
Middle Name:SUE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:BOBBIE
Other - Middle Name:SUE
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19910 STONEHILL DR
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-7673
Mailing Address - Country:US
Mailing Address - Phone:225-664-5099
Mailing Address - Fax:
Practice Address - Street 1:2308 S RANGE AVE
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-5216
Practice Address - Country:US
Practice Address - Phone:225-664-5099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA018346183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist