Healthcare Provider Details

I. General information

NPI: 1376557702
Provider Name (Legal Business Name): PATRICIA L JACKSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PATRICIA TRETHEWEY FNP

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 W CATALPA DR SUITE D
MISHAWAKA IN
46545-8321
US

IV. Provider business mailing address

230 CATALPA SUITE D
MISHAWAKA IN
46545
US

V. Phone/Fax

Practice location:
  • Phone: 574-257-7551
  • Fax: 574-257-7535
Mailing address:
  • Phone: 574-257-7551
  • Fax: 574-257-7535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71001911A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: