Provider Demographics
NPI:1194307033
Name:IWUEZE, JESSICA OLUCHI
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:OLUCHI
Last Name:IWUEZE
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 1:30 GARRISON ST APT 403
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5738
Mailing Address - Country:US
Mailing Address - Phone:469-408-4337
Mailing Address - Fax:
Practice Address - Street 1:1630 TREMONT ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02120-1613
Practice Address - Country:US
Practice Address - Phone:617-232-5457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH240062183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist