Provider Demographics
NPI:1255948345
Name:KICKLIGHTER, JACKSON ALLEN (PHARMD, MHA, BCMTMS)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:ALLEN
Last Name:KICKLIGHTER
Suffix:
Gender:M
Credentials:PHARMD, MHA, BCMTMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 MIDHURST DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-1462
Mailing Address - Country:US
Mailing Address - Phone:706-871-5549
Mailing Address - Fax:
Practice Address - Street 1:20 W BANK ST STE 6
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-3279
Practice Address - Country:US
Practice Address - Phone:804-835-5425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29807183500000X
VA0202219611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist