Healthcare Provider Details

I. General information

NPI: 1396189056
Provider Name (Legal Business Name): JESSICA LUCILLE HORAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 06/28/2022
Certification Date: 06/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 RILEY HOSPITAL DR ROOM RR 208
INDIANAPOLIS IN
46202-5119
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-4715
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR3227
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number02004849A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: