Provider Demographics
NPI:1649409897
Name:WOLF, JESSICA NELLIE (PHARMD, RPH)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:NELLIE
Last Name:WOLF
Suffix:
Gender:F
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 HORICON ST
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53050-1429
Mailing Address - Country:US
Mailing Address - Phone:920-387-7800
Mailing Address - Fax:920-387-7809
Practice Address - Street 1:1028 HORICON ST
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-1429
Practice Address - Country:US
Practice Address - Phone:920-387-7800
Practice Address - Fax:920-387-7809
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15604-40183500000X
MI5302036192183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist