Healthcare Provider Details

I. General information

NPI: 1104032614
Provider Name (Legal Business Name): JENNIFER ANN ZIMMER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 02/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 WEST DR XE 040
INDIANAPOLIS IN
46202-5272
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 130 PROVIDER ENROLLMENT
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-4000
  • Fax: 317-944-3622
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number01060483
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: