Healthcare Provider Details

I. General information

NPI: 1578013058
Provider Name (Legal Business Name): JENNIFER N BESEMER RD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER N AGOSTINO

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 E IRELAND RD
SOUTH BEND IN
46614-2845
US

IV. Provider business mailing address

3245 HEALTH DR STE 100
GRANGER IN
46530-1380
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1700
  • Fax: 574-647-7572
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number37002583A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: