Healthcare Provider Details

I. General information

NPI: 1063963619
Provider Name (Legal Business Name): ZACHARY LAWRENCE JESKO FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 W DIVISION ST
DEMOTTE IN
46310-8377
US

IV. Provider business mailing address

10548 N 100 W
WHEATFIELD IN
46392-9713
US

V. Phone/Fax

Practice location:
  • Phone: 219-987-7005
  • Fax: 862-298-0610
Mailing address:
  • Phone: 219-510-2515
  • Fax: 862-298-0610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0916896
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number28163653A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: