=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902247521
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYNETTE MICHELLE JACKSON PHARM.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2013
-----------------------------------------------------
Last Update Date | 07/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 HAMBURG TPKE SJWH PHARMACY DEPARTMENT
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-956-3395
-----------------------------------------------------
Fax | 973-389-4015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 PALISADE AVE APT 3F
-----------------------------------------------------
City | JERSEY CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07307-1714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-571-2261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 28RI03309200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------