Provider Demographics
NPI:1700534393
Name:MAURER, JACKSON PATRICK
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:PATRICK
Last Name:MAURER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 1/2 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4134
Mailing Address - Country:US
Mailing Address - Phone:269-924-6975
Mailing Address - Fax:
Practice Address - Street 1:2951 HEARTLAND CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-7669
Practice Address - Country:US
Practice Address - Phone:270-359-7510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-14
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0238971835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist