Provider Demographics
NPI:1750770574
Name:KAMPF, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:KAMPF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-2051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2323 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4508
Practice Address - Country:US
Practice Address - Phone:414-291-1069
Practice Address - Fax:414-291-1073
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15697-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist