Provider Demographics
NPI:1992858708
Name:TIEDEMANN, JENNA L (BA, PHARMD)
Entity Type:Individual
Prefix:MS
First Name:JENNA
Middle Name:L
Last Name:TIEDEMANN
Suffix:
Gender:F
Credentials:BA, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 MAPLE ROAD
Mailing Address - Street 2:
Mailing Address - City:WI
Mailing Address - State:NY
Mailing Address - Zip Code:14224-1324
Mailing Address - Country:US
Mailing Address - Phone:716-656-4070
Mailing Address - Fax:
Practice Address - Street 1:1540 MAPLE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3647
Practice Address - Country:US
Practice Address - Phone:716-568-3784
Practice Address - Fax:716-568-3780
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist