Provider Demographics
NPI:1326390402
Name:EGGERS, JONATHAN ALLAN
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ALLAN
Last Name:EGGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 TESSERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NEKOOSA
Mailing Address - State:WI
Mailing Address - Zip Code:54457-7508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 TESSERVILLE RD
Practice Address - Street 2:
Practice Address - City:NEKOOSA
Practice Address - State:WI
Practice Address - Zip Code:54457-7508
Practice Address - Country:US
Practice Address - Phone:715-315-0059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-12
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66571183500000X
WI16880-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist