Provider Demographics
NPI:1477753051
Name:JACOBS, BRENDA LEE (RPH)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:LEE
Last Name:JACOBS
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 US HWY 14
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0309
Mailing Address - Country:US
Mailing Address - Phone:608-754-7414
Mailing Address - Fax:608-754-1777
Practice Address - Street 1:2500 US HWY 14
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0309
Practice Address - Country:US
Practice Address - Phone:608-754-7414
Practice Address - Fax:608-754-1777
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11159183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist