Provider Demographics
NPI:1982244810
Name:TEWELL, JACQUELINE RENEE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENEE
Last Name:TEWELL
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 1:3390 CAMERON CHASE DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-2872
Mailing Address - Country:US
Mailing Address - Phone:850-980-0085
Mailing Address - Fax:
Practice Address - Street 1:3122 MAHAN DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-2500
Practice Address - Country:US
Practice Address - Phone:840-402-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-08
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS60363183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist