Provider Demographics
NPI:1780047860
Name:KOLWYCK, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KOLWYCK
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 1:1102 N GATEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37854-4012
Mailing Address - Country:US
Mailing Address - Phone:865-354-1571
Mailing Address - Fax:865-354-1987
Practice Address - Street 1:168 OBED PLZ
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-8871
Practice Address - Country:US
Practice Address - Phone:931-484-5109
Practice Address - Fax:931-707-8561
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist