=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568109254
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER AVERSANO FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2022
-----------------------------------------------------
Last Update Date | 02/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 85 E US HIGHWAY 6 STE 200
-----------------------------------------------------
City | VALPARAISO
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46383-8947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-962-4084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2022 KELLE DR
-----------------------------------------------------
City | CHESTERTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46304-8708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-962-4084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71013004A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------