Healthcare Provider Details

I. General information

NPI: 1861362220
Provider Name (Legal Business Name): JENNIFER ANN O'DANIEL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6435 W JEFFERSON BLVD # 434
FORT WAYNE IN
46804-6203
US

IV. Provider business mailing address

PO BOX 843603
DALLAS TX
75284-3603
US

V. Phone/Fax

Practice location:
  • Phone: 260-436-7875
  • Fax: 260-432-9812
Mailing address:
  • Phone: 407-667-0444
  • Fax: 407-667-4338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28285850A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: