Provider Demographics
NPI:1770251530
Name:WOODRUFF, JACQUESE LYNEL (PHARMD)
Entity Type:Individual
Prefix:MS
First Name:JACQUESE
Middle Name:LYNEL
Last Name:WOODRUFF
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 1:11013 CALERA PSGE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:IN
Mailing Address - Zip Code:46783-8606
Mailing Address - Country:US
Mailing Address - Phone:260-200-8714
Mailing Address - Fax:
Practice Address - Street 1:10627 DIEBOLD RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8606
Practice Address - Country:US
Practice Address - Phone:260-470-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-04
Last Update Date:2021-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN45022964A390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program