Provider Demographics
NPI:1164798476
Name:IN, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:IN
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 1:9773 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1010
Mailing Address - Country:US
Mailing Address - Phone:215-673-0747
Mailing Address - Fax:215-973-2050
Practice Address - Street 1:9773 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1010
Practice Address - Country:US
Practice Address - Phone:215-673-0747
Practice Address - Fax:215-973-2050
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP439770183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist