Active NPI
Jackleen Fan
- Pharmacist
- Evans, GA
National Provider Identifier
1407337306
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- RPH030830
- Practice address
- 4310 Washington Rd
Evans, GA 30809-3957 - Phone
- (706) 860-4179
- NPI assigned
- Aug 28, 2018
- Last updated
- Aug 28, 2018
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | RPH030830 | GA | Primary |
Addresses
Primary practice location
4310 Washington Rd
Evans, GA 30809-3957
Mailing address
372 Collins Glen CT
Lawrenceville, GA 30043-6848
Phone (706) 773-9237
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| RPH030830 | GA | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Walgreen Co | Past | Accepting new patients | |
| Walgreen Co | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1535414400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1535414400000",
"number": "1407337306",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "372 COLLINS GLEN CT",
"city": "LAWRENCEVILLE",
"state": "GA",
"postal_code": "300436848",
"telephone_number": "706-773-9237"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4310 WASHINGTON RD",
"city": "EVANS",
"state": "GA",
"postal_code": "308093957",
"telephone_number": "706-860-4179"
}
],
"practiceLocations": [],
"basic": {
"last_name": "FAN",
"first_name": "JACKLEEN",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2018-08-28",
"last_updated": "2018-08-28",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "GA",
"license": "RPH030830",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Evans, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.