Provider Demographics
NPI:1093545279
Name:MICKEVICIUS, JESSICA LYNN (PHARMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:MICKEVICIUS
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13405 W BURLEIGH RD APT 103
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-3053
Mailing Address - Country:US
Mailing Address - Phone:262-853-1763
Mailing Address - Fax:
Practice Address - Street 1:725 AMERICAN AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-5031
Practice Address - Country:US
Practice Address - Phone:262-928-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-03
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2271340183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist