=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831840198
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAITLIN RAEANN JACKSON PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2022
-----------------------------------------------------
Last Update Date | 01/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 S 12TH ST
-----------------------------------------------------
City | MURRAY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42071-9303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-767-6960
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3005 E WOOD ST
-----------------------------------------------------
City | PARIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38242-9630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-436-0713
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 44557
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 021952
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------