Healthcare Provider Details

I. General information

NPI: 1962996314
Provider Name (Legal Business Name): JORDYNN OLIVIA TIBBS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 09/27/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9250 COLUMBIA AVE STE 2E
MUNSTER IN
46321-3530
US

IV. Provider business mailing address

9250 COLUMBIA AVE STE 2E
MUNSTER IN
46321-3530
US

V. Phone/Fax

Practice location:
  • Phone: 219-595-0043
  • Fax: 219-237-2894
Mailing address:
  • Phone: 219-595-0043
  • Fax: 219-237-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71008634A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: