Provider Demographics
NPI:1598053100
Name:FONSECA, JESSICA DAWN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:DAWN
Last Name:FONSECA
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 1:200 FERGUSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4028
Mailing Address - Country:US
Mailing Address - Phone:307-630-5973
Mailing Address - Fax:
Practice Address - Street 1:700 S GREELEY HWY
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-2848
Practice Address - Country:US
Practice Address - Phone:307-635-4087
Practice Address - Fax:307-637-3197
Is Sole Proprietor?:No
Enumeration Date:2011-07-16
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS018576183500000X
WY3488183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist