Provider Demographics
NPI:1700377488
Name:EDMONDS, JACQUIE LYNN
Entity Type:Individual
Prefix:
First Name:JACQUIE
Middle Name:LYNN
Last Name:EDMONDS
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 1:8300 W 135TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66223-1143
Mailing Address - Country:US
Mailing Address - Phone:913-402-4352
Mailing Address - Fax:913-402-4370
Practice Address - Street 1:8300 W 135TH ST
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66223-1143
Practice Address - Country:US
Practice Address - Phone:913-402-4352
Practice Address - Fax:913-402-4370
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-12632183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist