Provider Demographics
NPI:1366266033
Name:JACKSON, SEGREENA (RPH)
Entity type:Individual
Prefix:
First Name:SEGREENA
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OCEAN ST APT 12
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-4733
Mailing Address - Country:US
Mailing Address - Phone:781-885-4607
Mailing Address - Fax:
Practice Address - Street 1:105 DAVIS STRAITS
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-3909
Practice Address - Country:US
Practice Address - Phone:508-540-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH1001121183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist