MEDICARE: JENNY LIN THERIAULT

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
1	163W00000X	Registered Nurse	28266113A	IN

General Provider Information

NPI Number	:	1740019736
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNY LIN THERIAULT

Provider Business Mailing Address
First Line	:	3516 E 10TH ST
Second Line	:
City	:	JEFFERSONVILLE
State	:	IN
Zip	:	47130-9315
Country	:	US
Telephone Number	:	812-704-3288
Fax Number	:

Provider Business Practice Location Address
First Line	:	3516 E 10TH ST
Second Line	:
City	:	JEFFERSONVILLE
State	:	IN
Zip	:	47130-9315
Country	:	US
Telephone Number	:	812-704-3288
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/29/2024
Last Update Date	:	08/04/2024

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