Healthcare Provider Details

I. General information

NPI: 1689358087
Provider Name (Legal Business Name): JENNIFER ASUQUO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8028 CARNEGIE BLVD STE 100
FORT WAYNE IN
46804-5789
US

IV. Provider business mailing address

11109 PARKVIEW PLAZA DR # 117
FORT WAYNE IN
46845-1701
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-9200
  • Fax: 260-425-6914
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01099496A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: