Provider Demographics
NPI:1902384811
Name:JACKSON, NIEKA (PHARMD)
Entity Type:Individual
Prefix:
First Name:NIEKA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 WOODLAWN DR
Mailing Address - Street 2:APT. C-1
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021
Mailing Address - Country:US
Mailing Address - Phone:803-673-2162
Mailing Address - Fax:
Practice Address - Street 1:75 WOODLAWN DR
Practice Address - Street 2:APT. C-1
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021
Practice Address - Country:US
Practice Address - Phone:803-673-2162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC37835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist