Healthcare Provider Details

I. General information

NPI: 1487885679
Provider Name (Legal Business Name): JENNIFER C EWING NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 03/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5340 HOLY CROSS PKWY
MISHAWAKA IN
46545-1470
US

IV. Provider business mailing address

3975 WILLIAM RICHARDSON DR
SOUTH BEND IN
46628-9800
US

V. Phone/Fax

Practice location:
  • Phone: 800-860-8100
  • Fax: 574-237-1341
Mailing address:
  • Phone: 800-860-8100
  • Fax: 574-237-1341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberPENDING
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: