Provider Demographics
NPI:1376661934
Name:JEROME D. JACKSON
Entity type:Organization
Organization Name:JEROME D. JACKSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-452-2328
Mailing Address - Street 1:1867 AIRPORT WAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4007
Mailing Address - Country:US
Mailing Address - Phone:907-452-2328
Mailing Address - Fax:
Practice Address - Street 1:1867 AIRPORT WAY
Practice Address - Street 2:SUITE 105
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4007
Practice Address - Country:US
Practice Address - Phone:907-452-2328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK312332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK0200624OtherNABP NUMBER
AKMSO268Medicaid
AKPHO268Medicaid
AKPHO268Medicaid
AKMSO268Medicaid