Healthcare Provider Details

I. General information

NPI: 1548982812
Provider Name (Legal Business Name): MRS. JENNIFER LEIGH DEFAUW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 GLENDALE BLVD # 102A
VALPARAISO IN
46383-3767
US

IV. Provider business mailing address

2753 KERRY DR
VALPARAISO IN
46385-0031
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-9521
  • Fax:
Mailing address:
  • Phone: 219-331-8183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71013190A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: