Provider Demographics
NPI:1023383783
Name:MATTOON, JENNIFER LYNN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:MATTOON
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 1:101 ENMAN KINCAID RD
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-9687
Mailing Address - Country:US
Mailing Address - Phone:509-397-9999
Mailing Address - Fax:
Practice Address - Street 1:101 ENMAN KINCAID RD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-9687
Practice Address - Country:US
Practice Address - Phone:509-397-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00062636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist