Provider Demographics
NPI:1811260417
Name:JANKE, JAY P (RPH)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:P
Last Name:JANKE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 S ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4582
Mailing Address - Country:US
Mailing Address - Phone:414-313-1904
Mailing Address - Fax:
Practice Address - Street 1:704 S ADAMS ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4582
Practice Address - Country:US
Practice Address - Phone:414-313-1904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47291183500000X
WI10350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist