Provider Demographics
NPI:1760983209
Name:JACKSON, KASEY LEIGH (PHARMD)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:LEIGH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2300 SOUTH BLVD APT 155
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6462
Mailing Address - Country:US
Mailing Address - Phone:843-845-2359
Mailing Address - Fax:980-442-3002
Practice Address - Street 1:1021 MOREHEAD MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2990
Practice Address - Country:US
Practice Address - Phone:980-442-3083
Practice Address - Fax:980-442-3002
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251511835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology