Provider Demographics
NPI:1558924084
Name:TRAUTWEIN, JACQUELINE RENEE (RPH)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENEE
Last Name:TRAUTWEIN
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 1:4700 BOARDWALK DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3729
Mailing Address - Country:US
Mailing Address - Phone:970-204-7817
Mailing Address - Fax:970-204-7819
Practice Address - Street 1:4700 BOARDWALK DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3729
Practice Address - Country:US
Practice Address - Phone:970-204-7817
Practice Address - Fax:970-204-7819
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist