Healthcare Provider Details

I. General information

NPI: 1689480493
Provider Name (Legal Business Name): ELIZABETH JANSMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12750 SAINT FRANCIS DR
CROWN POINT IN
46307-0264
US

IV. Provider business mailing address

705 8TH AVE NE
DEMOTTE IN
46310-8024
US

V. Phone/Fax

Practice location:
  • Phone: 219-274-1334
  • Fax:
Mailing address:
  • Phone: 219-776-9811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License Number2024072183
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: