Healthcare Provider Details

I. General information

NPI: 1457262024
Provider Name (Legal Business Name): KENDRA LEA JACKSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15731 105TH WAY SE
YELM WA
98597-8465
US

IV. Provider business mailing address

15731 105TH WAY SE
YELM WA
98597-8465
US

V. Phone/Fax

Practice location:
  • Phone: 360-915-4201
  • Fax:
Mailing address:
  • Phone: 360-915-4201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11428997-8911
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPHRM.PH.61333720
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: