Provider Demographics
NPI:1417330457
Name:FORTUNE, JESSICA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:FORTUNE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 MAYFLOWER XING BLDG D
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6271
Mailing Address - Country:US
Mailing Address - Phone:781-350-8324
Mailing Address - Fax:
Practice Address - Street 1:1111 E END BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0030
Practice Address - Country:US
Practice Address - Phone:570-824-3521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPI157481183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist