Provider Demographics
NPI:1265037188
Name:HENRICKSEN, JACOB (PHARMD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HENRICKSEN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11221 SYNERGY DR APT 366
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-1351
Mailing Address - Country:US
Mailing Address - Phone:763-202-9618
Mailing Address - Fax:
Practice Address - Street 1:3726 22ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53140-5300
Practice Address - Country:US
Practice Address - Phone:262-654-6545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20472-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty