Healthcare Provider Details

I. General information

NPI: 1851342190
Provider Name (Legal Business Name): JEANETTE P JEFFERIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 WISHARD BLVD 4TH FL
INDIANAPOLIS IN
46202-2872
US

IV. Provider business mailing address

8910 PURDUE RD SUITE 500
INDIANAPOLIS IN
46268-3161
US

V. Phone/Fax

Practice location:
  • Phone: 317-630-7979
  • Fax:
Mailing address:
  • Phone: 317-871-8811
  • Fax: 317-871-8833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71000204A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number71000204A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: