Healthcare Provider Details

I. General information

NPI: 1790195600
Provider Name (Legal Business Name): JENNIFER R DAAKE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 W TIPTON ST
SEYMOUR IN
47274-2363
US

IV. Provider business mailing address

411 W TIPTON ST
SEYMOUR IN
47274-2363
US

V. Phone/Fax

Practice location:
  • Phone: 812-522-2349
  • Fax: 812-522-0507
Mailing address:
  • Phone: 812-522-2349
  • Fax: 812-522-0507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001684A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: