Healthcare Provider Details

I. General information

NPI: 1124625926
Provider Name (Legal Business Name): JAY LEE HOEKSEMA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 09/23/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 E MAIN ST
PERU IN
46970-2662
US

IV. Provider business mailing address

8003 CASTLEWAY DR
INDIANAPOLIS IN
46250-1946
US

V. Phone/Fax

Practice location:
  • Phone: 765-472-2519
  • Fax: 765-400-4465
Mailing address:
  • Phone: 317-576-1335
  • Fax: 317-343-6562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71010433A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28160280A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71010433A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: