Provider Demographics
NPI:1487976288
Name:JACKSON, CLARENCE RHEA
Entity type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:RHEA
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 1:230 LONG HOLLOW PIKE
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-1880
Mailing Address - Country:US
Mailing Address - Phone:615-859-3498
Mailing Address - Fax:615-855-2112
Practice Address - Street 1:230 LONG HOLLOW PIKE
Practice Address - Street 2:
Practice Address - City:GOODLETTSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37072-1880
Practice Address - Country:US
Practice Address - Phone:615-859-3498
Practice Address - Fax:615-855-2112
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1870183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist