Healthcare Provider Details

I. General information

NPI: 1245518927
Provider Name (Legal Business Name): JESSICA L SLATTERY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA L HAASE CNP

II. Dates (important events)

Enumeration Date: 07/28/2011
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 E 7TH ST STE A
AUBURN IN
46706-2537
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-925-1255
  • Fax: 260-925-1256
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.12439-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71014774A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: