Healthcare Provider Details

I. General information

NPI: 1043747462
Provider Name (Legal Business Name): JENIFFER FORSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENIFFER ESHUN

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 03/22/2022
Certification Date: 03/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3611 S REED RD STE 108
KOKOMO IN
46902-3828
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 765-776-3700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01087033A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: