Provider Demographics
NPI:1649338682
Name:MICHAUD, JESSICA BETH (PHARMD, BCPS)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:BETH
Last Name:MICHAUD
Suffix:
Gender:F
Credentials:PHARMD, BCPS
Other - Prefix:DR
Other - First Name:JESSICA
Other - Middle Name:BETH
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD, BCPS
Mailing Address - Street 1:1857 N 73RD ST
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-2254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.2894481835P1200X
WI16578-401835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL051.289448OtherIL STATE LICENSE
WI16578-40OtherWI LICENSE
OH03-1-24675OtherOH STATE LICENSE