Provider Demographics
NPI:1639235146
Name:BRISCOE, JACQUELYN LEE (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELYN
Middle Name:LEE
Last Name:BRISCOE
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9365 W KLINGER RD
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45318-9643
Mailing Address - Country:US
Mailing Address - Phone:937-473-3031
Mailing Address - Fax:419-375-4488
Practice Address - Street 1:110 EAST BUTLER ST
Practice Address - Street 2:
Practice Address - City:FORT RECOVERY
Practice Address - State:OH
Practice Address - Zip Code:45846-0605
Practice Address - Country:US
Practice Address - Phone:419-375-2323
Practice Address - Fax:419-375-4488
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-2-26302183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist