Provider Demographics
NPI:1215690524
Name:FLACK, JESSICA LENORE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LENORE
Last Name:FLACK
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 1:8901 STATE ROUTE 30
Mailing Address - Street 2:
Mailing Address - City:NORTH HUNTINGDON
Mailing Address - State:PA
Mailing Address - Zip Code:15642
Mailing Address - Country:US
Mailing Address - Phone:724-864-7481
Mailing Address - Fax:
Practice Address - Street 1:8901 STATE ROUTE 30
Practice Address - Street 2:
Practice Address - City:NORTH HUNTINGDON
Practice Address - State:PA
Practice Address - Zip Code:15642-2704
Practice Address - Country:US
Practice Address - Phone:724-864-7481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP441534183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist