Healthcare Provider Details

I. General information

NPI: 1700211828
Provider Name (Legal Business Name): JASON WHITE F.N.P., B.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2013
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 MACARTHUR BLVD SUITE 404
MUNSTER IN
46321-2915
US

IV. Provider business mailing address

801 MACARTHUR BLVD SUITE 404
MUNSTER IN
46321-2915
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-2995
  • Fax: 219-836-4075
Mailing address:
  • Phone: 219-836-2995
  • Fax: 219-836-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28182542A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: