Basic Information
| Provider Information | |||||||||
| NPI: | 1083014484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUTNEY | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAWTHORNE | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 830 CHALKSTONE AVE | ||||||||
| Address2: | PROVIDENCE VA MEDICAL CENTER | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029084734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4012737100 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 718 SMYTH RD | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031047007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036244366 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2014 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P0018X | PH235261 | MA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 1835P1300X | PH235261 | MA | Y | Pharmacy Service Providers | Pharmacist | Psychiatric |
No ID Information.