Provider Demographics
NPI:1164129151
Name:VERDICK, JENNA
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:VERDICK
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 1:131 DORSET CT APT 15
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5581
Mailing Address - Country:US
Mailing Address - Phone:630-809-4325
Mailing Address - Fax:
Practice Address - Street 1:6505 N ILLINOIS ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2001
Practice Address - Country:US
Practice Address - Phone:618-394-8744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician