Provider Demographics
NPI:1306115639
Name:JACKSON, MILISSA (DPH)
Entity type:Individual
Prefix:
First Name:MILISSA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7830 GREENWICH DR W
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-8407
Mailing Address - Country:US
Mailing Address - Phone:901-690-8900
Mailing Address - Fax:
Practice Address - Street 1:1863 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-4028
Practice Address - Country:US
Practice Address - Phone:901-272-2006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000010138183500000X
MST-09517183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist