Provider Demographics
NPI:1902188600
Name:JACKSON, REGINA DENISE (PHARM D)
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:DENISE
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 1:2220 HEWATT RD
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-4021
Mailing Address - Country:US
Mailing Address - Phone:770-978-4157
Mailing Address - Fax:770-978-6563
Practice Address - Street 1:2220 HEWATT RD
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-4021
Practice Address - Country:US
Practice Address - Phone:770-978-4157
Practice Address - Fax:770-978-6563
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH020468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist