Healthcare Provider Details

I. General information

NPI: 1205300886
Provider Name (Legal Business Name): JON PHILIP HAUTZENROEDER CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 LINKS WAY
AURORA IN
47001-1403
US

IV. Provider business mailing address

PO BOX 635283
CINCINNATI OH
45263-5283
US

V. Phone/Fax

Practice location:
  • Phone: 812-926-3133
  • Fax: 812-926-1668
Mailing address:
  • Phone: 812-926-3133
  • Fax: 812-926-1668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71011058A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: