Healthcare Provider Details

I. General information

NPI: 1760589477
Provider Name (Legal Business Name): MR. JEFFREY SCOTT JACKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16821 ROSMAN HWY
LAKE TOXAWAY NC
28747-9593
US

IV. Provider business mailing address

426 MAPLE ST
BREVARD NC
28712-3879
US

V. Phone/Fax

Practice location:
  • Phone: 828-884-3784
  • Fax: 828-884-3792
Mailing address:
  • Phone: 828-966-4462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10953
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: