Provider Demographics
NPI:1336559632
Name:JACKSON, KAY ELLEN (RPH)
Entity type:Individual
Prefix:
First Name:KAY
Middle Name:ELLEN
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 1:4735 BENTLEY DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-4447
Mailing Address - Country:US
Mailing Address - Phone:248-885-8678
Mailing Address - Fax:
Practice Address - Street 1:1005 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:MADISON HTS
Practice Address - State:MI
Practice Address - Zip Code:48071-1533
Practice Address - Country:US
Practice Address - Phone:248-307-4933
Practice Address - Fax:248-307-4965
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020271001835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy