Provider Demographics
NPI:1962771972
Name:ENGEBRETSON, JESSICA ELAINE (PHARMD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELAINE
Last Name:ENGEBRETSON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 130TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-7108
Mailing Address - Country:US
Mailing Address - Phone:612-840-6316
Mailing Address - Fax:
Practice Address - Street 1:3605 ROUND LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANOKA
Practice Address - State:MN
Practice Address - Zip Code:55303-5003
Practice Address - Country:US
Practice Address - Phone:763-252-0751
Practice Address - Fax:763-252-0757
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN119351183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist