Provider Demographics
NPI:1669926804
Name:JACKSON, AMANDA (PHARMD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-4843
Mailing Address - Country:US
Mailing Address - Phone:847-406-2261
Mailing Address - Fax:
Practice Address - Street 1:3001 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-4843
Practice Address - Country:US
Practice Address - Phone:847-406-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2020-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051297625183500000X
NC24803183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist