Healthcare Provider Details

I. General information

NPI: 1356271084
Provider Name (Legal Business Name): JEREMY ROSS MANN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2026
Last Update Date: 06/28/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5215 HOLY CROSS PKWY
MISHAWAKA IN
46545-1469
US

IV. Provider business mailing address

18685 BEACH WAY
SOUTH BEND IN
46637-4207
US

V. Phone/Fax

Practice location:
  • Phone: 800-498-7157
  • Fax:
Mailing address:
  • Phone: 574-323-5503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28242991A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: