Provider Demographics
NPI:1992028203
Name:BORGESON, JENNIFER L (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:BORGESON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19051 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-8672
Mailing Address - Country:US
Mailing Address - Phone:815-485-4531
Mailing Address - Fax:
Practice Address - Street 1:11100 S. CICERO AVE
Practice Address - Street 2:KMART PHARMACY
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453
Practice Address - Country:US
Practice Address - Phone:708-424-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.286722183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist