Provider Demographics
NPI:1023757192
Name:JACKSON, MARISSA NOELLE (PHARMD)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:NOELLE
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 1:3278 MITCHELL BLVD
Mailing Address - Street 2:
Mailing Address - City:MOODY AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31699-1500
Mailing Address - Country:US
Mailing Address - Phone:229-257-3221
Mailing Address - Fax:
Practice Address - Street 1:MOODY AIRFORCE BASE
Practice Address - Street 2:BEMISS ROAD
Practice Address - City:DPO
Practice Address - State:AA
Practice Address - Zip Code:31699
Practice Address - Country:US
Practice Address - Phone:229-257-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL62552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62552Medicaid