Provider Demographics
NPI:1770925505
Name:JACKSON, PENNY (RPH)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:JACKSON
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 1:9395 GREENCASTLE RD
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47805-9631
Mailing Address - Country:US
Mailing Address - Phone:812-877-2546
Mailing Address - Fax:812-877-2546
Practice Address - Street 1:801 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-2261
Practice Address - Country:US
Practice Address - Phone:765-832-1224
Practice Address - Fax:765-832-1295
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020678A183500000X
TX38011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist