Provider Demographics
NPI:1578252748
Name:BAISLEY, JENNIFER KANGVAN (CPHT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KANGVAN
Last Name:BAISLEY
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-4906
Mailing Address - Country:US
Mailing Address - Phone:509-339-9371
Mailing Address - Fax:
Practice Address - Street 1:1630 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-4906
Practice Address - Country:US
Practice Address - Phone:509-339-9371
Practice Address - Fax:509-334-4415
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA60791279183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician