Provider Demographics
NPI:1508251737
Name:ULM, JACQUELIN
Entity Type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:
Last Name:ULM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACQUELIN
Other - Middle Name:
Other - Last Name:BOURBONAIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:1409 COUNTRY CLUB LN
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-4350
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:624 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094-6229
Practice Address - Country:US
Practice Address - Phone:920-261-7140
Practice Address - Fax:920-261-8223
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9652-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist