Provider Demographics
NPI:1801401690
Name:PONDER, JESSICA SUZANNE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SUZANNE
Last Name:PONDER
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 1:1807 W FRANK AVE
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-5108
Mailing Address - Country:US
Mailing Address - Phone:936-634-8394
Mailing Address - Fax:936-634-4068
Practice Address - Street 1:1807 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-5108
Practice Address - Country:US
Practice Address - Phone:936-634-8394
Practice Address - Fax:936-634-4068
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40105183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist