Provider Demographics
NPI:1629658273
Name:CAIN, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:CAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 WHITEHALL CT
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-2718
Mailing Address - Country:US
Mailing Address - Phone:618-977-0421
Mailing Address - Fax:
Practice Address - Street 1:10 SOUTHGATE CTR
Practice Address - Street 2:
Practice Address - City:FREEBURG
Practice Address - State:IL
Practice Address - Zip Code:62243-1541
Practice Address - Country:US
Practice Address - Phone:618-539-5577
Practice Address - Fax:618-539-3089
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.295953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist