Healthcare Provider Details

I. General information

NPI: 1467134635
Provider Name (Legal Business Name): JACOB THOMAS CANNESTRA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2023
Last Update Date: 06/13/2026
Certification Date: 06/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 W PIONEER RD
FOND DU LAC WI
54935-6151
US

IV. Provider business mailing address

315 LAMPERT ST
OSHKOSH WI
54901-5303
US

V. Phone/Fax

Practice location:
  • Phone: 920-923-7780
  • Fax:
Mailing address:
  • Phone: 414-581-2807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number22272-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: