Healthcare Provider Details

I. General information

NPI: 1578761144
Provider Name (Legal Business Name): ASHRAF JEWELL PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 WEST WILLOW RD
DALE IN
47523
US

IV. Provider business mailing address

2615 E BLACKFORD AVE
EVANSVILLE IN
47714-2543
US

V. Phone/Fax

Practice location:
  • Phone: 812-937-4489
  • Fax: 812-937-7101
Mailing address:
  • Phone: 812-476-7414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06001045A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: