Provider Demographics
NPI:1760589477
Name:JACKSON, JEFFREY SCOTT
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:SCOTT
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-3879
Mailing Address - Country:US
Mailing Address - Phone:828-966-4462
Mailing Address - Fax:
Practice Address - Street 1:16821 ROSMAN HWY
Practice Address - Street 2:
Practice Address - City:LAKE TOXAWAY
Practice Address - State:NC
Practice Address - Zip Code:28747-9593
Practice Address - Country:US
Practice Address - Phone:828-884-3784
Practice Address - Fax:828-884-3792
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1170260001Medicare ID - Type Unspecified