Provider Demographics
NPI:1588264501
Name:ALFORD, JESSICA RENEE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:RENEE
Last Name:ALFORD
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 1:7162 S 100 E
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-7828
Mailing Address - Country:US
Mailing Address - Phone:812-698-4465
Mailing Address - Fax:
Practice Address - Street 1:1801 S STATE ROAD 57
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-4541
Practice Address - Country:US
Practice Address - Phone:812-698-4465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26021419A1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1835P0018XMedicaid