Provider Demographics
NPI:1447534482
Name:NUSSBAUM, JACQUELIN RAE (RPH)
Entity type:Individual
Prefix:MRS
First Name:JACQUELIN
Middle Name:RAE
Last Name:NUSSBAUM
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 1:12753 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CLIVE
Mailing Address - State:IA
Mailing Address - Zip Code:50325-8246
Mailing Address - Country:US
Mailing Address - Phone:515-226-1786
Mailing Address - Fax:
Practice Address - Street 1:12753 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8246
Practice Address - Country:US
Practice Address - Phone:515-226-1786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA17861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist