Provider Demographics
NPI:1487094942
Name:JACKSON, ECOLA (CPHT)
Entity type:Individual
Prefix:
First Name:ECOLA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 S PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-4400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5525 S PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-4400
Practice Address - Country:US
Practice Address - Phone:773-432-0100
Practice Address - Fax:773-432-0101
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049.166756183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician