Provider Demographics
NPI:1154760569
Name:EASTMAN, JENNIFER (CPHT)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:EASTMAN
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W 9TH ST N
Mailing Address - Street 2:
Mailing Address - City:LADYSMITH
Mailing Address - State:WI
Mailing Address - Zip Code:54848-1249
Mailing Address - Country:US
Mailing Address - Phone:715-532-6614
Mailing Address - Fax:715-532-9293
Practice Address - Street 1:400 W 9TH ST N
Practice Address - Street 2:
Practice Address - City:LADYSMITH
Practice Address - State:WI
Practice Address - Zip Code:54848-1249
Practice Address - Country:US
Practice Address - Phone:715-532-6614
Practice Address - Fax:715-532-9293
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1007071183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician