Provider Demographics
NPI:1104100114
Name:FEHRENBACHER, JAN E
Entity type:Individual
Prefix:MRS
First Name:JAN
Middle Name:E
Last Name:FEHRENBACHER
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 1:603 WOODLAWN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656
Mailing Address - Country:US
Mailing Address - Phone:217-732-1825
Mailing Address - Fax:217-732-7796
Practice Address - Street 1:603 WOODLAWN
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656
Practice Address - Country:US
Practice Address - Phone:217-732-1825
Practice Address - Fax:217-732-7796
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-041193183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist