Healthcare Provider Details

I. General information

NPI: 1891189320
Provider Name (Legal Business Name): JENNA ELISE WALLS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5255 E STOP 11 RD STE 310
INDIANAPOLIS IN
46237-6341
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 317-781-1133
  • Fax: 317-837-4640
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01079238A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number1079238A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: