Healthcare Provider Details

I. General information

NPI: 1063239846
Provider Name (Legal Business Name): JACQUELINE LEE HENRY APRN-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE LEE MICHUDA APRN-NP

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 UNIVERSITY COMMONS
SOUTH BEND IN
46635-1571
US

IV. Provider business mailing address

6301 UNIVERSITY COMMONS
SOUTH BEND IN
46635-1571
US

V. Phone/Fax

Practice location:
  • Phone: 574-251-1210
  • Fax:
Mailing address:
  • Phone: 574-251-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10033768
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10033768
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28301774A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: