Provider Demographics
NPI:1114110178
Name:ANDERSON, JESSICA (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ANDERSON
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 1:40520 COUNTY HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:OGEMA
Mailing Address - State:MN
Mailing Address - Zip Code:56569-9612
Mailing Address - Country:US
Mailing Address - Phone:218-983-6375
Mailing Address - Fax:218-983-6384
Practice Address - Street 1:40520 COUNTY HIGHWAY 34
Practice Address - Street 2:
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569-9612
Practice Address - Country:US
Practice Address - Phone:218-983-6375
Practice Address - Fax:218-983-6384
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118927183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist