Individual
JACOB HENRICKSEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PHARMD
Contact information
Practice address
3726 22ND AVE, KENOSHA, WI 53140-5300
(262) 654-6545
Mailing address
11221 SYNERGY DR APT 366, WAUWATOSA, WI 53222-1351
(763) 202-9618
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
20472-40
WI
Other
Enumeration date
11/30/2020
Last updated
11/30/2020
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