Provider Demographics
NPI:1003105669
Name:MARCUM, JENNIFER M
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:MARCUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CRESLEY BRANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:ULYSSES
Mailing Address - State:KY
Mailing Address - Zip Code:41224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 CRESLEY BRANCH ROAD
Practice Address - Street 2:
Practice Address - City:ULYSSES
Practice Address - State:KY
Practice Address - Zip Code:41224
Practice Address - Country:US
Practice Address - Phone:606-673-1161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY012903183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist