Provider Demographics
NPI:1134786411
Name:COBURN, JENNIFER DIANE (RPH)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:DIANE
Last Name:COBURN
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:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:BREMOND
Mailing Address - State:TX
Mailing Address - Zip Code:76629-0160
Mailing Address - Country:US
Mailing Address - Phone:254-746-7845
Mailing Address - Fax:
Practice Address - Street 1:101 S AUSTIN ST
Practice Address - Street 2:
Practice Address - City:BREMOND
Practice Address - State:TX
Practice Address - Zip Code:76629-5036
Practice Address - Country:US
Practice Address - Phone:254-746-7845
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT38371183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist