Provider Demographics
NPI:1669900684
Name:JACKSON, JESSICA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
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 1:9248 CONCORD PARK DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-9301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1717 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:AL
Practice Address - Zip Code:36832-5870
Practice Address - Country:US
Practice Address - Phone:205-601-4358
Practice Address - Fax:205-601-4358
Is Sole Proprietor?:No
Enumeration Date:2017-06-03
Last Update Date:2017-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16871183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL16871OtherPHARMACY LICENSE