Provider Demographics
NPI:1447448154
Name:JACKSON, ERIN DORAINE (PHARMD, CDM)
Entity type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:DORAINE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHARMD, CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 NW 16TH ST # 150
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2271
Mailing Address - Country:US
Mailing Address - Phone:208-452-7075
Mailing Address - Fax:208-452-7446
Practice Address - Street 1:1620 N WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2129
Practice Address - Country:US
Practice Address - Phone:208-452-7075
Practice Address - Fax:208-452-7446
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV16162183500000X
OR0011841183500000X
UT9031849-1701183500000X
IDP5601183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist