Provider Demographics
NPI:1497563696
Name:TANNER, JESSICA NICOLE (PHARMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NICOLE
Last Name:TANNER
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:PO BOX 4007
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456-4007
Mailing Address - Country:US
Mailing Address - Phone:606-308-3859
Mailing Address - Fax:
Practice Address - Street 1:14949 N US HIGHWAY 25 E
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-6285
Practice Address - Country:US
Practice Address - Phone:606-280-4212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY021662183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist