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NPI Code Detail

MEDICARE: JENNY SUE EVERSMAN PTA

MEDICARE: JENNY SUE EVERSMAN PTA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1174400000XSpecialist06002991AIN

General Provider Information

NPI Number : 1568793248
Entity Type Code : Individual
Provider Name (Legal Business Name) : JENNY SUE EVERSMAN PTA
Provider Business Mailing Address
First Line : 5837 W WALLEN RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46818-9363
Country : US
Telephone Number : 260-715-2850
Fax Number :
Provider Business Practice Location Address
First Line : 2827 NORTHGATE BLVD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46835-2900
Country : US
Telephone Number : 260-715-2850
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/20/2010
Last Update Date : 01/20/2010

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Directions to “ JENNY SUE EVERSMAN PTA” Practice Location

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