Provider Demographics
NPI:1891315370
Name:JACKSON, JANELL LENNICE C (PHARM D)
Entity Type:Individual
Prefix:
First Name:JANELL
Middle Name:LENNICE C
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-0005
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3670 RIVERDALE ROAD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115
Practice Address - Country:US
Practice Address - Phone:901-309-2621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40258183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN40258Medicaid
ARPD13744Medicaid