Healthcare Provider Details

I. General information

NPI: 1538782685
Provider Name (Legal Business Name): HEATHER JACKSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER WEBSTER

II. Dates (important events)

Enumeration Date: 05/23/2020
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 ANNE ST NW
BEMIDJI MN
56601-5114
US

IV. Provider business mailing address

47 ROCHDALE RD
POUGHKEEPSIE NY
12603-1421
US

V. Phone/Fax

Practice location:
  • Phone: 218-333-2450
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number059464
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: