Provider Demographics
NPI:1609754001
Name:JACKSON, KATHLEEN LYNN (RPH)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LYNN
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:FARIS
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2836 COUNTY ROAD 962D
Mailing Address - Street 2:
Mailing Address - City:ALVIN
Mailing Address - State:TX
Mailing Address - Zip Code:77511-8667
Mailing Address - Country:US
Mailing Address - Phone:281-705-2679
Mailing Address - Fax:
Practice Address - Street 1:950 HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:FOLCROFT
Practice Address - State:PA
Practice Address - Zip Code:19032-1805
Practice Address - Country:US
Practice Address - Phone:855-790-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-25
Last Update Date:2025-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26396183500000X
PARP459033183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist