Healthcare Provider Details

I. General information

NPI: 1912276361
Provider Name (Legal Business Name): JACQUELINE MONROE D.P.M
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7559 W JEFFERSON BLVD
FORT WAYNE IN
46804-4131
US

IV. Provider business mailing address

7559 W JEFFERSON BLVD
FORT WAYNE IN
46804-4131
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-3579
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.003581
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001138A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: