Healthcare Provider Details

I. General information

NPI: 1578802112
Provider Name (Legal Business Name): JENNIFER MAKI NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5718 CRAWFORDSVILLE RD
INDIANAPOLIS IN
46224-3704
US

IV. Provider business mailing address

5718 CRAWFORDSVILLE RD
INDIANAPOLIS IN
46224-3704
US

V. Phone/Fax

Practice location:
  • Phone: 317-240-5001
  • Fax: 317-240-5010
Mailing address:
  • Phone: 317-240-5001
  • Fax: 317-240-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28202055A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71004328A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: