Provider Demographics
NPI:1902106610
Name:MADDEN, JAMIE LYNN
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:MADDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 COFFEEN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-4804
Mailing Address - Country:US
Mailing Address - Phone:307-672-1788
Mailing Address - Fax:307-672-5206
Practice Address - Street 1:169 COFFEEN AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-4804
Practice Address - Country:US
Practice Address - Phone:307-672-1788
Practice Address - Fax:307-672-5206
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY2764183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist