Provider Demographics
NPI:1982331161
Name:TERRY, JACKIE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:
Other - Last Name:PENSEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:3270 S 1300 E
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84106-3099
Mailing Address - Country:US
Mailing Address - Phone:801-487-5461
Mailing Address - Fax:
Practice Address - Street 1:3270 S 1300 E
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84106-3099
Practice Address - Country:US
Practice Address - Phone:801-487-5461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-06
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6346089183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT6346089OtherDOPL