Provider Demographics
NPI:1598192247
Name:EWERT, JESSICA LYNN (PHARMD)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:EWERT
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:MS
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:KOEHLERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:3200 8TH ST S
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54494-6563
Mailing Address - Country:US
Mailing Address - Phone:715-424-4082
Mailing Address - Fax:715-424-4868
Practice Address - Street 1:3200 8TH ST S
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54494-6563
Practice Address - Country:US
Practice Address - Phone:715-424-4082
Practice Address - Fax:715-424-4868
Is Sole Proprietor?:No
Enumeration Date:2013-09-26
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17106-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist