Healthcare Provider Details

I. General information

NPI: 1568845295
Provider Name (Legal Business Name): JIYOUNG CHAE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 09/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 SAGAMORE PKWY W
WEST LAFAYETTE IN
47906-1501
US

IV. Provider business mailing address

PO BOX 5777
MARYVILLE TN
37802-5777
US

V. Phone/Fax

Practice location:
  • Phone: 765-448-8000
  • Fax:
Mailing address:
  • Phone: 865-246-2104
  • Fax: 865-246-2106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28193970A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71005808A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: