Provider Demographics
NPI:1669561155
Name:MUSHINSKY, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MUSHINSKY
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 1:728 W DEERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1025
Mailing Address - Country:US
Mailing Address - Phone:309-690-0069
Mailing Address - Fax:
Practice Address - Street 1:201 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:IL
Practice Address - Zip Code:61610-4039
Practice Address - Country:US
Practice Address - Phone:309-699-9571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15824183500000X
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist