Provider Demographics
NPI:1124313739
Name:PUCKETT, JENNIFER ANN (PHARMD)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:ANN
Last Name:PUCKETT
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 1:755 NW GILMAN BLVD
Mailing Address - Street 2:T-0996
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5357
Mailing Address - Country:US
Mailing Address - Phone:425-507-1020
Mailing Address - Fax:425-507-1020
Practice Address - Street 1:755 NW GILMAN BLVD
Practice Address - Street 2:T-0996
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5357
Practice Address - Country:US
Practice Address - Phone:425-507-1020
Practice Address - Fax:425-507-1020
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-10
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60093679183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist