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General NPI Number Information
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NPI Number | 1760765945
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Entity Type | Individual
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Provider Name | JENNIFER RAYE MYERS PAC
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Gender | Female
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Dates
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Enumeration Date | 09/23/2011
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Last Update Date | 09/21/2020
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Provider Practice Location Address
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Address Line | 7333 W JEFFERSON BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46804-6280
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Country | US
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Telephone | 260-435-7334
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Fax |
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Provider Business Mailing Address
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Address Line | 7333 W JEFFERSON BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46804-6280
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Country | US
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Telephone | 260-458-3830
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 10001764A
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License Number State | IN
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