Provider Demographics
NPI:1114401130
Name:LI, JESSE T
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:T
Last Name:LI
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 1:145 W CACHE VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-8473
Mailing Address - Country:US
Mailing Address - Phone:435-787-0495
Mailing Address - Fax:435-787-9269
Practice Address - Street 1:145 W CACHE VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-8473
Practice Address - Country:US
Practice Address - Phone:435-787-0495
Practice Address - Fax:435-787-9269
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT71208501701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist