Provider Demographics
NPI:1174946115
Name:JACKSON, MARILYN (PHARMD, MBA)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 HEATHROW DR
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-7807
Mailing Address - Country:US
Mailing Address - Phone:214-405-8095
Mailing Address - Fax:
Practice Address - Street 1:1055 HEATHROW DR
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-7807
Practice Address - Country:US
Practice Address - Phone:214-405-8095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39836183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist