Healthcare Provider Details

I. General information

NPI: 1801722582
Provider Name (Legal Business Name): JENNIFER MALCOLM NP
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

17 ORIOLE DR
LAFAYETTE IN
47905-8787
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-2143
  • Fax:
Mailing address:
  • Phone: 219-869-1852
  • Fax: 219-869-1852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71018285A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: