Healthcare Provider Details

I. General information

NPI: 1043985880
Provider Name (Legal Business Name): JESSICA ROSE BALDWIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6050 STERLING CREEK RD
PORTAGE IN
46368-7752
US

IV. Provider business mailing address

6050 STERLING CREEK RD
PORTAGE IN
46368-7752
US

V. Phone/Fax

Practice location:
  • Phone: 219-763-8112
  • Fax:
Mailing address:
  • Phone: 219-983-2926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71011563A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number28230582A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: