Provider Demographics
NPI:1821261355
Name:JACKSON, JERRY W
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:W
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPH
Mailing Address - Street 1:801 STADIUM DR
Mailing Address - Street 2:SUITE # 111
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-6254
Mailing Address - Country:US
Mailing Address - Phone:817-226-5050
Mailing Address - Fax:
Practice Address - Street 1:801 STADIUM DR
Practice Address - Street 2:SUITE # 111
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-6254
Practice Address - Country:US
Practice Address - Phone:817-226-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19512183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist