Provider Demographics
NPI:1346228418
Name:SIEFERT, JENNIFER A (RPH)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:SIEFERT
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4450 N PROSPECT RD STE 7
Mailing Address - Street 2:
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-6578
Mailing Address - Country:US
Mailing Address - Phone:309-679-2047
Mailing Address - Fax:309-679-2051
Practice Address - Street 1:4450 N PROSPECT RD STE 7
Practice Address - Street 2:
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-6578
Practice Address - Country:US
Practice Address - Phone:309-679-2047
Practice Address - Fax:309-679-2051
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051036576183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist