Provider Demographics
NPI:1528312345
Name:BROOKSHAW, JASEN KENNETH (PHARMD, RPH)
Entity type:Individual
Prefix:
First Name:JASEN
Middle Name:KENNETH
Last Name:BROOKSHAW
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 S ACCESS RD
Mailing Address - Street 2:
Mailing Address - City:RICE LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54868-8572
Mailing Address - Country:US
Mailing Address - Phone:715-236-7414
Mailing Address - Fax:
Practice Address - Street 1:320 S ACCESS RD
Practice Address - Street 2:
Practice Address - City:RICE LAKE
Practice Address - State:WI
Practice Address - Zip Code:54868-8572
Practice Address - Country:US
Practice Address - Phone:715-236-7414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16693-40183500000X
MN121036183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist