Healthcare Provider Details

I. General information

NPI: 1033119904
Provider Name (Legal Business Name): REGINA R. JASIEWICZ FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 09/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

IV. Provider business mailing address

211 N EDDY ST
SOUTH BEND IN
46617-2808
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-9231
  • Fax: 574-237-9208
Mailing address:
  • Phone: 574-237-9231
  • Fax: 574-237-9208

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000519A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: