Provider Demographics
NPI:1487885679
Name:EWING, JENNIFER C (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:C
Last Name:EWING
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3975 WILLIAM RICHARDSON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-9800
Mailing Address - Country:US
Mailing Address - Phone:800-860-8100
Mailing Address - Fax:574-237-1341
Practice Address - Street 1:5340 HOLY CROSS PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1470
Practice Address - Country:US
Practice Address - Phone:800-860-8100
Practice Address - Fax:574-237-1341
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INPENDING363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1487885679Medicaid
IN1487885679Medicaid