Healthcare Provider Details

I. General information

NPI: 1407710957
Provider Name (Legal Business Name): JAMI LEANNE HALLIBURTON NCCHHA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5888 W KING FISHER DR
MENTONE IN
46539-9313
US

IV. Provider business mailing address

5888 W KING FISHER DR
MENTONE IN
46539-9313
US

V. Phone/Fax

Practice location:
  • Phone: 574-377-4812
  • Fax:
Mailing address:
  • Phone: 574-377-4812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number20255097P
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: