Provider Demographics
NPI:1992413074
Name:JACKSON, LA'DAIJA
Entity type:Individual
Prefix:DR
First Name:LA'DAIJA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 POND DR
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-4283
Mailing Address - Country:US
Mailing Address - Phone:601-325-6615
Mailing Address - Fax:
Practice Address - Street 1:170 LEONTYNE PRICE BLVD
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4428
Practice Address - Country:US
Practice Address - Phone:601-428-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-100949183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist