Provider Demographics
NPI:1952421927
Name:JACKSON, JEFFREY W (RPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5510 LAFAYETTE RD STE 260
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-1691
Mailing Address - Country:US
Mailing Address - Phone:317-803-3436
Mailing Address - Fax:317-803-3437
Practice Address - Street 1:5510 LAFAYETTE RD STE 260
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-1691
Practice Address - Country:US
Practice Address - Phone:317-803-3436
Practice Address - Fax:317-803-3437
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26019318A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist