MEDICARE: SUNDAY LEE JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	RP036528L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	RP036528L	OTHER	PA	LICENSE
2	RPI013554	OTHER	PA	INJECTION AUTHORIZATION

General Provider Information

NPI Number	:	1013547967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUNDAY LEE JACKSON

Provider Business Mailing Address
First Line	:	1001 7TH AVE
Second Line	:
City	:	DUNCANSVILLE
State	:	PA
Zip	:	16635-1338
Country	:	US
Telephone Number	:	814-329-6096
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 BLAIR ST
Second Line	:
City	:	HOLLIDAYSBURG
State	:	PA
Zip	:	16648-2445
Country	:	US
Telephone Number	:	814-696-0289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2020
Last Update Date	:	01/20/2020

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Directions to “ SUNDAY LEE JACKSON ” Practice Location

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