Healthcare Provider Details

I. General information

NPI: 1881167997
Provider Name (Legal Business Name): JARA LYNN SOUTHERLAND NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 E 38TH ST
INDIANAPOLIS IN
46205-2748
US

IV. Provider business mailing address

PO BOX 746720
ATLANTA GA
30374-6720
US

V. Phone/Fax

Practice location:
  • Phone: 463-249-2314
  • Fax: 317-245-2388
Mailing address:
  • Phone: 312-733-9730
  • Fax: 773-866-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71008724A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number71008724A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: