Provider Demographics
NPI:1942260351
Name:JACKSON, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
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 1:620 15TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IA
Mailing Address - Zip Code:52314-4701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 WINDFLOWER LN STE 100
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:IA
Practice Address - Zip Code:52333-4708
Practice Address - Country:US
Practice Address - Phone:319-624-2239
Practice Address - Fax:319-624-3186
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA19165183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist