Healthcare Provider Details

I. General information

NPI: 1093430365
Provider Name (Legal Business Name): JENNIFER EUNICE MOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2022
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6131 US HIGHWAY 6
PORTAGE IN
46368-5058
US

IV. Provider business mailing address

6131 US HIGHWAY 6
PORTAGE IN
46368-5058
US

V. Phone/Fax

Practice location:
  • Phone: 219-841-9788
  • Fax:
Mailing address:
  • Phone: 219-841-9788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28207864A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: