Provider Demographics
NPI:1467866855
Name:DISSELKAMP, JESSICA (PHARMD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DISSELKAMP
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 1:540 SHIPLEY RD
Mailing Address - Street 2:
Mailing Address - City:CECILIA
Mailing Address - State:KY
Mailing Address - Zip Code:42724-8716
Mailing Address - Country:US
Mailing Address - Phone:270-300-6493
Mailing Address - Fax:
Practice Address - Street 1:445 HIGHWAY 44 E
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-6020
Practice Address - Country:US
Practice Address - Phone:502-543-2355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY016225183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist