Provider Demographics
NPI:1790319234
Name:JACKSON, PETER ALLEN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ALLEN
Last Name:JACKSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 N MILITARY AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-3202
Mailing Address - Country:US
Mailing Address - Phone:920-498-3247
Mailing Address - Fax:
Practice Address - Street 1:116 N MILITARY AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-3202
Practice Address - Country:US
Practice Address - Phone:920-498-3247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI18622-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist