Healthcare Provider Details

I. General information

NPI: 1689914681
Provider Name (Legal Business Name): JENNIFER ELIZABETH KOSCIOLEK DPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5995 STAGE RD
BARTLETT TN
38134-8311
US

IV. Provider business mailing address

10136 MACKWOOD DR
LAKELAND TN
38002-8380
US

V. Phone/Fax

Practice location:
  • Phone: 901-385-7097
  • Fax: 901-385-7098
Mailing address:
  • Phone: 901-385-7097
  • Fax: 901-385-7098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11676
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: