Healthcare Provider Details

I. General information

NPI: 1649164781
Provider Name (Legal Business Name): THOMAS JACKSON JUNG PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2025
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 W JOHNSON ST
FOND DU LAC WI
54935-2076
US

IV. Provider business mailing address

4901 CONNEMARA CT APT 13
SHEBOYGAN WI
53083-1297
US

V. Phone/Fax

Practice location:
  • Phone: 920-929-7422
  • Fax:
Mailing address:
  • Phone: 262-515-8445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number22700-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: