Provider Demographics
NPI:1023132107
Name:IVERSON, JENNIFER S (RPH)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:IVERSON
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 1:301 NP AVE N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4835
Mailing Address - Country:US
Mailing Address - Phone:701-271-1495
Mailing Address - Fax:
Practice Address - Street 1:301 NP AVE N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4835
Practice Address - Country:US
Practice Address - Phone:701-271-1495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND4966183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist