Healthcare Provider Details

I. General information

NPI: 1679000525
Provider Name (Legal Business Name): JESSICA RAYNER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 FIR ST SUITE 320
EAST CHICAGO IN
46312-3076
US

IV. Provider business mailing address

4320 FIR STREET SUITE 320
EAST CHICAGO IN
46312
US

V. Phone/Fax

Practice location:
  • Phone: 219-392-7992
  • Fax:
Mailing address:
  • Phone: 219-392-7992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71007243A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: