Provider Demographics
NPI:1902371800
Name:JACKSON, JADE INDIRA
Entity Type:Individual
Prefix:
First Name:JADE
Middle Name:INDIRA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33023-6756
Mailing Address - Country:US
Mailing Address - Phone:754-260-6711
Mailing Address - Fax:
Practice Address - Street 1:301 S STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33023-6756
Practice Address - Country:US
Practice Address - Phone:754-260-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-06
Last Update Date:2018-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58372183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist