Provider Demographics
NPI:1063936987
Name:JACKSON, DEVEN
Entity type:Individual
Prefix:
First Name:DEVEN
Middle Name:
Last Name:JACKSON
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 1:805 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28803-1011
Mailing Address - Country:US
Mailing Address - Phone:828-298-3636
Mailing Address - Fax:
Practice Address - Street 1:805 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-1011
Practice Address - Country:US
Practice Address - Phone:828-298-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27176183500000X
GARPH029970183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist