Provider Demographics
NPI:1568072999
Name:ANDERSON, JENNA LYNNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:LYNNE
Last Name:ANDERSON
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:W2677 MOURNING DOVE LN
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53508-9803
Mailing Address - Country:US
Mailing Address - Phone:608-220-7385
Mailing Address - Fax:
Practice Address - Street 1:21 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53536-1143
Practice Address - Country:US
Practice Address - Phone:608-882-4550
Practice Address - Fax:608-882-0149
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19475-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist