Provider Demographics
NPI:1457747065
Name:VANDERSLICE, JENNIFER STEELE
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:STEELE
Last Name:VANDERSLICE
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 1:1753 NC 39 HWY S
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27549-7106
Mailing Address - Country:US
Mailing Address - Phone:252-937-4701
Mailing Address - Fax:847-396-2913
Practice Address - Street 1:720 SUTTERS CREEK BLVD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-8429
Practice Address - Country:US
Practice Address - Phone:252-937-4701
Practice Address - Fax:847-396-2913
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21635183500000X
SC11413183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist