Provider Demographics
NPI:1376128959
Name:JESPERSEN, DAN WESLEY (R PH)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:WESLEY
Last Name:JESPERSEN
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-3651
Mailing Address - Country:US
Mailing Address - Phone:972-298-4936
Mailing Address - Fax:972-296-9844
Practice Address - Street 1:302 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-3651
Practice Address - Country:US
Practice Address - Phone:972-298-4936
Practice Address - Fax:972-296-9844
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20234183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist