Healthcare Provider Details

I. General information

NPI: 1003061409
Provider Name (Legal Business Name): JOIE DEVIVRE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2008
Last Update Date: 11/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1535 PIAZZA DRIVE
BLOOMINGTON IN
47401
US

IV. Provider business mailing address

1535 PIAZZA DRIVE
BLOOMINGTON IN
47401
US

V. Phone/Fax

Practice location:
  • Phone: 812-334-2772
  • Fax:
Mailing address:
  • Phone: 812-334-2772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01052568A
License Number StateIN

VIII. Authorized Official

Name: DR. LISA J JERRELLS
Title or Position: MD
Credential: MD
Phone: 812-334-2772