Healthcare Provider Details

I. General information

NPI: 1669447900
Provider Name (Legal Business Name): JODI BULT N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 04/08/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15900 W 101ST AVE
DYER IN
46311-3065
US

IV. Provider business mailing address

15900 W 101ST AVE
DYER IN
46311-3065
US

V. Phone/Fax

Practice location:
  • Phone: 219-365-6333
  • Fax: 219-365-8291
Mailing address:
  • Phone: 219-365-6333
  • Fax: 219-365-8291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number071004325A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: