Provider Demographics
NPI:1043884174
Name:VANDEUSEN, JEANNINE R
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:R
Last Name:VANDEUSEN
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 1:409 N MARKETPLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-7732
Mailing Address - Country:US
Mailing Address - Phone:517-622-1451
Mailing Address - Fax:
Practice Address - Street 1:409 N MARKETPLACE BLVD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-7732
Practice Address - Country:US
Practice Address - Phone:517-622-1451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53033021852183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician