Provider Demographics
NPI:1639774573
Name:NICKELE, JENNIFER LEE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:NICKELE
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 1:1320 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804-3129
Mailing Address - Country:US
Mailing Address - Phone:812-242-2787
Mailing Address - Fax:812-235-6876
Practice Address - Street 1:1320 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-3129
Practice Address - Country:US
Practice Address - Phone:812-242-2787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022172A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist