Provider Demographics
NPI:1538720305
Name:JACKSON, KATHLEEN CELESTE (RPH, PHARMD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CELESTE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43203-1779
Mailing Address - Country:US
Mailing Address - Phone:614-336-2096
Mailing Address - Fax:
Practice Address - Street 1:181 TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-1779
Practice Address - Country:US
Practice Address - Phone:614-336-2096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03237243183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist