Provider Demographics
NPI:1013236009
Name:PETTY, JENNIFER SHARELL (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:SHARELL
Last Name:PETTY
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 1:3308 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-3028
Mailing Address - Country:US
Mailing Address - Phone:904-838-2804
Mailing Address - Fax:
Practice Address - Street 1:5108 NORWOOD AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-5032
Practice Address - Country:US
Practice Address - Phone:904-764-4491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-31
Last Update Date:2010-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45692183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist