Provider Demographics
NPI:1053642025
Name:KNUST, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:KNUST
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 1:2000 S DOUGLAS HWY
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-5414
Mailing Address - Country:US
Mailing Address - Phone:307-682-4517
Mailing Address - Fax:307-682-4563
Practice Address - Street 1:2000 S DOUGLAS HWY
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-5414
Practice Address - Country:US
Practice Address - Phone:307-682-4517
Practice Address - Fax:307-682-4563
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3009183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist