Provider Demographics
NPI:1710090519
Name:SAMPSELL, JENNIFER L (CPHT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:SAMPSELL
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 HAZEN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-1040
Mailing Address - Country:US
Mailing Address - Phone:269-657-4701
Mailing Address - Fax:269-657-4553
Practice Address - Street 1:404 HAZEN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1040
Practice Address - Country:US
Practice Address - Phone:269-657-4701
Practice Address - Fax:269-657-4553
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI110105271923093183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician