Provider Demographics
NPI:1023839693
Name:WIDENER, JENNIFER ANN (PHARMD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:WIDENER
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 1:714 W MARKET ST STE 101
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-5483
Mailing Address - Country:US
Mailing Address - Phone:423-328-9333
Mailing Address - Fax:
Practice Address - Street 1:714 W MARKET ST STE 101
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5483
Practice Address - Country:US
Practice Address - Phone:423-328-9333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202222366183500000X
TN48435183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist