Provider Demographics
NPI:1720141955
Name:ANDERSON, JO ELLEN
Entity type:Individual
Prefix:MRS
First Name:JO
Middle Name:ELLEN
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JO
Other - Middle Name:ELLEN
Other - Last Name:MONAHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:205 BITTERCREEK DRIVE
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630
Mailing Address - Country:US
Mailing Address - Phone:916-983-2899
Mailing Address - Fax:
Practice Address - Street 1:7223 FAIR OAKS BLVD
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608
Practice Address - Country:US
Practice Address - Phone:916-483-9961
Practice Address - Fax:916-483-9998
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7106183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician