Healthcare Provider Details

I. General information

NPI: 1215272224
Provider Name (Legal Business Name): JILLIAN R COLPITTS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2012
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N EDDY ST
SOUTH BEND IN
46617-3096
US

IV. Provider business mailing address

130 E CLEVELAND RD
GRANGER IN
46530-5620
US

V. Phone/Fax

Practice location:
  • Phone: 574-237-9231
  • Fax: 574-204-6355
Mailing address:
  • Phone: 866-389-2727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28177674A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: