Provider Demographics
NPI:1184924524
Name:JOHNSTON, JENNESSA R (NP)
Entity type:Individual
Prefix:MS
First Name:JENNESSA
Middle Name:R
Last Name:JOHNSTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNESSA
Other - Middle Name:R
Other - Last Name:CONDERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 130 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:806 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47305-1551
Practice Address - Country:US
Practice Address - Phone:765-281-4263
Practice Address - Fax:765-286-1737
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003503A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01303727OtherRAILROAD MEDICARE
IN201006660Medicaid
INP01303727OtherRAILROAD MEDICARE