Provider Demographics
NPI:1942941554
Name:OWEN, JACKIE (RPH)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:OWEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010A BARBOUR DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-7709
Mailing Address - Country:US
Mailing Address - Phone:217-251-7122
Mailing Address - Fax:
Practice Address - Street 1:4720B LEE HWY
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22207-3417
Practice Address - Country:US
Practice Address - Phone:703-524-9003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202220203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist