Provider Demographics
NPI:1477333532
Name:ALESNA, JACOB
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ALESNA
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:PO BOX 2608
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86405-2608
Mailing Address - Country:US
Mailing Address - Phone:808-542-8183
Mailing Address - Fax:
Practice Address - Street 1:80 ACOMA BLVD N
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6932
Practice Address - Country:US
Practice Address - Phone:928-680-4449
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS026639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist