Provider Demographics
NPI:1023392594
Name:BUSSIAN, JACLYN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JACLYN
Middle Name:
Last Name:BUSSIAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E CAMPUS MALL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1269
Mailing Address - Country:US
Mailing Address - Phone:608-251-0042
Mailing Address - Fax:608-251-6145
Practice Address - Street 1:311 E CAMPUS MALL
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1269
Practice Address - Country:US
Practice Address - Phone:608-251-0042
Practice Address - Fax:608-251-6145
Is Sole Proprietor?:No
Enumeration Date:2011-10-03
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15233-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist