Healthcare Provider Details

I. General information

NPI: 1477003507
Provider Name (Legal Business Name): JACQUELYN BREWER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9645 WESTFIELD BLVD
INDIANAPOLIS IN
46280-1771
US

IV. Provider business mailing address

9645 WESTFIELD BLVD
INDIANAPOLIS IN
46280-1771
US

V. Phone/Fax

Practice location:
  • Phone: 317-801-4035
  • Fax:
Mailing address:
  • Phone: 317-801-4035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: