Provider Demographics
NPI:1790098317
Name:JACKSON, LACEY J (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LACEY
Middle Name:J
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11815 FOUNTAIN WAY
Mailing Address - Street 2:ONE CITY CENTER SUITE 300
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4448
Mailing Address - Country:US
Mailing Address - Phone:757-926-5366
Mailing Address - Fax:
Practice Address - Street 1:11815 FOUNTAIN WAY
Practice Address - Street 2:ONE CITY CENTER SUITE 300
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4448
Practice Address - Country:US
Practice Address - Phone:757-926-5366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-24
Last Update Date:2010-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA02022074691835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist