Provider Demographics
NPI:1003410531
Name:WONTKA, JESSICA ALLEN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ALLEN
Last Name:WONTKA
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 1:4 KING RD
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01460-1629
Mailing Address - Country:US
Mailing Address - Phone:781-999-3918
Mailing Address - Fax:
Practice Address - Street 1:199 SUDBURY RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-3466
Practice Address - Country:US
Practice Address - Phone:978-371-0688
Practice Address - Fax:978-371-7922
Is Sole Proprietor?:No
Enumeration Date:2020-11-25
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH232509183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist