Provider Demographics
NPI:1922323294
Name:JACKSON, VANDELLE DIANNE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:VANDELLE
Middle Name:DIANNE
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 1:1913 OAK HILL AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-6335
Mailing Address - Country:US
Mailing Address - Phone:410-444-2543
Mailing Address - Fax:
Practice Address - Street 1:5100 SINCLAIR LN
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-5939
Practice Address - Country:US
Practice Address - Phone:410-483-3880
Practice Address - Fax:410-483-0931
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist