Healthcare Provider Details

I. General information

NPI: 1982956017
Provider Name (Legal Business Name): JEAN MARIE DECAVITCH NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JEAN MARIE SWENTON

II. Dates (important events)

Enumeration Date: 10/13/2012
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6831 W 133RD AVE
CEDAR LAKE IN
46303-8989
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-374-5970
  • Fax: 219-374-7505
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28125157A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71004201A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: