Provider Demographics
NPI:1508046863
Name:JANECEK, JENNIFER (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:JANECEK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:KINNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5144 ORANGEPORT RD
Mailing Address - Street 2:
Mailing Address - City:BREWERTON
Mailing Address - State:NY
Mailing Address - Zip Code:13029-9424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3035 EAST AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-2611
Practice Address - Country:US
Practice Address - Phone:315-668-7363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048936183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
048936OtherLICENSE NUMBER