Healthcare Provider Details

I. General information

NPI: 1316819626
Provider Name (Legal Business Name): MR. NATHAN EVAN JENNINGS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 SPRINGWOOD DR
AVON IN
46123-8788
US

IV. Provider business mailing address

221 SPRINGWOOD DR
AVON IN
46123-8788
US

V. Phone/Fax

Practice location:
  • Phone: 317-517-6088
  • Fax:
Mailing address:
  • Phone: 317-517-6088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71017207A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: